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Listopadzki T, Chowdhury A, Kohut K, Haider MN, Crane JK, Duquin T, DiPaola M. The effect of different antibiotic combinations in calcium sulfate cement on the growth of Cutibacterium acnes and Staphylococcus periprosthetic shoulder infection isolates. J Shoulder Elbow Surg 2024; 33:1457-1464. [PMID: 38417732 DOI: 10.1016/j.jse.2024.01.021] [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: 10/18/2023] [Revised: 12/17/2023] [Accepted: 01/01/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND Periprosthetic joint infections (PJI) of the shoulder are a devastating complication of shoulder arthroplasty and are commonly caused by Staphylococcus and Cutibacterium acnes. Absorbable calcium sulfate (CS) beads are sometimes used for delivering antibiotics in PJI. This study evaluates the in vitro effect of different combinations of gentamicin, vancomycin, and ertapenem in beads made from CS cement on the growth of C acnes and coagulase-negative Staphylococcus (CNS) strains. METHODS Three strains of C acnes and 5 strains of CNS from clinically proven shoulder PJI were cultured and plated with CS beads containing combinations of vancomycin, gentamicin, and ertapenem. Plates with C acnes were incubated anaerobically while plates with Staphylococcus were incubated aerobically at 37 °C. Zones of inhibition were measured at intervals of 3 and 7 days using a modified Kirby Bauer technique, and beads were moved to plates containing freshly streaked bacteria every seventh day. This process was run in triplicate over the course of 56 days. Statistical analysis was conducted using SPSS v. 28 with repeated measures analysis of variance (ANOVA) and pairwise comparisons with Tukey correction. RESULTS In experiments with C acnes, beads containing ertapenem + vancomycin and vancomycin alone formed the largest zones of inhibition over time (P < .001). In experiments with Staphylococcus, beads containing vancomycin alone formed the largest zones of inhibition over time for all 5 strains (P < .001). Zones of inhibition were 1.4x larger for C acnes than for Staphylococcus with beads containing vancomycin alone. For both C acnes and Staphylococcus, beads containing ertapenem had the strongest initial effect, preventing all bacterial growth in C acnes and almost all growth for Staphylococcus during the first week but dropping substantially by the second week. Beads containing gentamicin alone consistently created smaller zones of inhibition than beads containing vancomycin alone, with vancomycin producing zones 5.3x larger than gentamicin in C acnes and 1.3x larger in Staphylococcus (P < .001). DISCUSSION These data suggest that for both C acnes and Staphylococcal species, CS beads impregnated with vancomycin were most effective at producing a robust antibiotic effect. Additionally, ertapenem may be a viable supplement in order to create a more potent initial antibiotic effect but is not as effective as vancomycin when used alone. Gentamicin alone was not effective in maintaining consistent and long-term antibiotic effects. These results indicate that amongst the antibiotics currently commercially available to be used with CS, vancomycin is consistently superior to gentamicin in the setting of C. acnes and CNS.
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Affiliation(s)
- Thomas Listopadzki
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Science, University at Buffalo, The State University of New York at Buffalo, Buffalo, NY, USA
| | - Allison Chowdhury
- Jacobs School of Medicine and Biomedical Science, University at Buffalo, The State University of New York at Buffalo, Buffalo, NY, USA
| | - Kevin Kohut
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Science, University at Buffalo, The State University of New York at Buffalo, Buffalo, NY, USA
| | - Mohammad Nadir Haider
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Science, University at Buffalo, The State University of New York at Buffalo, Buffalo, NY, USA
| | - John K Crane
- Division of Infectious Disease, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, The State University of New York at Buffalo, Buffalo, NY, USA
| | - Thomas Duquin
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Science, University at Buffalo, The State University of New York at Buffalo, Buffalo, NY, USA
| | - Matthew DiPaola
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Science, University at Buffalo, The State University of New York at Buffalo, Buffalo, NY, USA.
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Marigi IM, Yu K, Nieboer MJ, Marigi EM, Sperling JW, Sanchez-Sotelo J, Barlow JD. After primary shoulder arthroplasty appropriate vancomycin antibiotic prophylaxis does not lead to increased infectious complications when compared to cefazolin. J Shoulder Elbow Surg 2024:S1058-2746(24)00358-6. [PMID: 38759838 DOI: 10.1016/j.jse.2024.03.059] [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: 11/01/2023] [Revised: 03/15/2024] [Accepted: 03/25/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND In primary shoulder arthroplasty (SA), intravenous (IV) cefazolin has demonstrated lower rates of infectious complications when compared to IV vancomycin. However, previous analyses included SA cohorts with both complete and incomplete vancomycin administration. Therefore, it is currently unclear whether cefazolin still maintains a prophylactic advantage to vancomycin when it is appropriately indicated and sufficiently administered at the time of surgical incision. This study evaluated the comparative efficacy of cefazolin and complete vancomycin administration for surgical prophylaxis in primary shoulder arthroplasty with respect to infectious complications. METHODS A retrospective cohort study was conducted utilizing a single institution total joint registry database, where all primary SA types (hemiarthroplasty, anatomic total shoulder arthroplasty, and reverse shoulder arthroplasty) performed between 2000 to 2019 for elective and trauma indications using IV cefazolin or complete vancomycin administration as the primary antibiotic prophylaxis were identified. Vancomycin was primarily indicated for patients with a severe self-reported penicillin or cephalosporin allergy and/or MRSA colonization. Complete administration was defined as at least 30 minutes of antibiotic infusion prior to incision. All included SA had at least 2 years of clinical follow-up. Multivariable Cox proportional hazard regression was used to evaluate all-cause infectious complications including survival free of prosthetic joint infection (PJI). RESULTS The final cohort included 7177 primary SA, 6879 (95.8%) received IV cefazolin and 298 (4.2%) received complete vancomycin administration. Infectious complications occurred in 120 (1.7%) SA leading to 81 (1.1%) infectious reoperations. Of the infectious complications, 41 (0.6%) were superficial infections and 79 were (1.1%) PJIs. When categorized by administered antibiotics, there were no differences in rates of all infectious complications (1.6% vs. 2.3%; P = .352), superficial complications (0.5% vs. 1.3%; P = .071), PJI (1.1% vs. 1.0%; P = .874), or infectious reoperations (1.1% vs. 1.0%; P = .839). On multivariable analyses, complete vancomycin infusion demonstrated no difference in rates of infectious complications compared to cefazolin administration (hazard ratio [HR], 1.50 [95% confidence interval (CI), 0.70 to 3.25]; P = .297), even when other independent predictors of PJI (male sex, prior surgery, and Methicillin-resistant Staphylococcus aureus colonization) were considered. CONCLUSIONS In comparison to cefazolin, complete administration of vancomycin (infusion to incision time greater than 30 minutes) as the primary prophylactic agent does not adversely increase the rates of infectious complications and PJI. Prophylaxis protocols should promote appropriate indications for the use of cefazolin or vancomycin, and when necessary, ensure complete administration of vancomycin to mitigate additional infectious risks after primary SA.
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Affiliation(s)
- Ian M Marigi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Kristin Yu
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Micah J Nieboer
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Erick M Marigi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - John W Sperling
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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Lovallo JL, Murray RS, Wiesel BB, Curley AJ, Conroy CM, Johnson DC. Intraoperative Intra-articular Antibiotic Injection Reduces Infection in Shoulder Arthroplasty. Orthopedics 2023; 46:310-314. [PMID: 36853948 DOI: 10.3928/01477447-20230224-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
Deep infection is a debilitating complication after shoulder arthroplasty. The authors hypothesized that an intra-articular, intraoperative injection of antibiotics would result in a lower infection rate compared with intravenous antibiotics alone. Before 2007, 164 patients (group A) did not receive intra-articular antibiotics. From 2007 to 2018, 1324 patients (group B) received intra-articular antibiotics. Patients received intra-articular gentamicin at the end of surgery with the addition of 1 g of cefazolin in January 2014. Records were retrospectively reviewed for comorbidities, type of surgery, and infection. The cohort that received intra-articular antibiotics was compared with the cohort that did not to determine the effect of prophylactic intra-articular antibiotic administration in preventing infection. There was 1 deep infection in the antibiotic group compared with 5 in the non-antibiotic group (P<.001). Superficial infections developed in 2 cases of patients treated with antibiotics; there were no superficial infections in patients treated without antibiotics (P=.62). One previous study evaluated intra-articular injection of antibiotics for shoulder arthroplasty and found significantly lower rates of infection with the injection of intra-articular gentamicin. In this retrospective follow-up study, the injection of intra-articular gentamicin or gentamicin and cefazolin effectively decreased rates of postoperative infection. At mean follow-up of 399 days, intra-articular antibiotics at the time of surgery resulted in significantly fewer deep infections. Given the minimal risk of adverse events and minimal cost, this is a valid method of reducing infections in total shoulder arthroplasty. [Orthopedics. 2023;46(5):310-314.].
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Kohm K, Seneca K, Smith K, Heinemann D, Nahass RG. Successful Treatment of Cutibacterium acnes Prosthetic Joint Infection With Single-Stage Exchange and Oral Antibiotics. Open Forum Infect Dis 2023; 10:ofad370. [PMID: 37539065 PMCID: PMC10394724 DOI: 10.1093/ofid/ofad370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 07/12/2023] [Indexed: 08/05/2023] Open
Abstract
Interest has grown in less invasive surgical treatment and early use of oral antibiotics in the treatment of Cutibacterium acnes prosthetic joint infection. We report a series of patients who were successfully treated with single-stage exchange and an all-oral course of rifampin and linezolid.
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Affiliation(s)
- Kevin Kohm
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | | | | | | | - Ronald G Nahass
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
- ID Care, Hillsborough New Jersey, USA
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Ashby NS, Johnson TJ, Castillo-Ronquillo Y, Payne CJ, Davenport C, Hoopes PC, Moshirfar M. Cutibacterium (Formerly Propionibacterium ) acnes Keratitis: A Review. Eye Contact Lens 2023; 49:212-218. [PMID: 36888541 DOI: 10.1097/icl.0000000000000975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
ABSTRACT Infectious keratitis is a devastating cause of vision loss worldwide. Cutibacterium acnes ( C. acnes ), a commensal bacterium of the skin and ocular surface, is an underrecognized but important cause of bacterial keratitis. This review presents the most comprehensive and up-to-date information for clinicians regarding the risk factors, incidence, diagnosis, management, and prognosis of C. acnes keratitis (CAK). Risk factors are similar to those of general bacterial keratitis and include contact lens use, past ocular surgery, and trauma. The incidence of CAK may be approximately 10%, ranging from 5% to 25% in growth-positive cultures. Accurate diagnosis requires anaerobic blood agar and a long incubation period (≥7 days). Typical clinical presentation includes small (<2 mm) ulcerations with deep stromal infiltrate causing an anterior chamber cell reaction. Small, peripheral lesions are usually resolved, and patients recover a high visual acuity. Severe infections causing VA of 20/200 or worse are common and often do not significantly improve even after treatment. Vancomycin is considered the most potent antibiotic against CAK, although other antibiotics such as moxifloxacin and ceftazidime are more commonly used as first-line treatment.
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Affiliation(s)
- Nathaniel S Ashby
- Creighton University School of Medicine (N.S.A.), Omaha, NE; Spencer Fox Eccles School of Medicine at the University of Utah (T.J.J.), Salt Lake City, UT; Hoopes Vision Research Center (Y.C.-R., C.J.P., C.D., P.C.H., M.M.), Hoopes Vision, Draper, UT; Case Western Reserve University School of Medicine (C.J.P.), Cleveland, OH; John A. Moran Eye Center (M.M.), Department of Ophthalmology and Visual Sciences, University of Utah School of Medicine, Salt Lake City, UT; and Utah Lions Eye Bank (M.M.), Murray, UT
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Dettmer A, Melander M, Björnsson Hallgren HC, Adolfsson LE, Salomonsson B. The Choice of Antibiotic Prophylaxis Influences the Infection Reoperation Rate in Primary Shoulder Arthroplasty: Analysis From the Swedish Shoulder Arthroplasty Register. Clin Orthop Relat Res 2023; 481:728-734. [PMID: 36410009 PMCID: PMC10013674 DOI: 10.1097/corr.0000000000002466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 09/30/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Periprosthetic joint infection is a serious complication and a major reason for revision surgery after primary shoulder arthroplasty. The prophylactic antibiotics for primary shoulder arthroplasty that have predominantly been used in Sweden are cloxacillin and clindamycin. To address Cutibacteriumacnes , benzylpenicillin has recently increasingly been added to cloxacillin, but it is unclear which antibiotic prophylaxis regimen is the most effective to prevent periprosthetic joint infection. QUESTIONS/PURPOSES After controlling for baseline differences among patients such as age, gender, previous surgery, cement fixation, and arthroplasty type, was the risk of reoperation for infection higher in patients who received cloxacillin than in those who received clindamycin or the combination of benzylpenicillin and cloxacillin? METHODS Data from the Swedish Shoulder Arthroplasty Register were used for this study. The inclusion criterion was registered antibiotic prophylaxis in primary arthroplasty. Between January 1, 1999, and December 31, 2019, 22,470 primary shoulder arthroplasties, including total shoulder, hemiarthroplasty, and reverse shoulder arthroplasties, were entered into the Swedish Shoulder Arthroplasty Register. Reporting of antibiotic prophylaxis to the register was introduced on January 1, 2013. Since then, the completeness of information on the type of antibiotic prophylaxis in the reports has been 85.3%. Consequently, 10,706 arthroplasties were eligible and fulfilled the inclusion criterion of reported antibiotic prophylaxis. A further 129 were excluded because of unusual prophylaxis regimens, leaving 10,577 shoulder arthroplasties for analysis. The Swedish Shoulder Arthroplasty Register gathers information from all 60 hospitals performing shoulder arthroplasty in Sweden, and through a comparison with the National Patient Register, it has been estimated that more than 90% of all primary shoulder arthroplasties and shoulder reoperations are reported to the register. The age of the study population ranged between 16 and 98 years; the mean age at the primary surgery was 70 ± 10 years for the entire cohort, with a mean age of 67 ± 10 years and 72 ± 9 years for men and women, respectively. The mean observation period was 989 ± 669 days. From 2013 to 2019, there was a clear change in prophylaxis; in particular, the use of the combination of benzylpenicillin and cloxacillin increased dramatically and the use of cloxacillin alone decreased. Clindamycin prophylaxis increased moderately. The primary study endpoint was reported reoperation for infection. In the register, this is defined as repeat procedures of any kind, including biopsy, lavage of the joint, or revision, defined as secondary surgery in which a component was exchanged, removed, or added. To compare the reoperation rate in relation to the different antibiotics used, which changed over time, we controlled for age, gender, previous surgery, cement fixation, and arthroplasty type using a Cox proportional hazards model. RESULTS When adjusting for age, gender, previous surgery, cement fixation, and arthroplasty type, cloxacillin prophylaxis was associated with an increased relative risk of reoperation for infection compared with the combination of cloxacillin and benzylpenicillin (hazard ratio [HR] 2.40 [95% confidence interval (CI) 1.35 to 4.25]; p = 0.003) and compared with clindamycin alone (HR 1.78 [95% CI 1.11 to 2.85]; p = 0.02). No difference was found between the cloxacillin and benzylpenicillin combination and clindamycin (HR 0.74 [95% CI 0.42 to 1.32]; p = 0.31). CONCLUSION Our results indicate that prophylaxis against C. acnes may be warranted in shoulder arthroplasty. Because the absolute number of infections was low and infections could have been underreported to the register, our results should be interpreted with caution. There is no available information about the causative microorganisms. The study lays the groundwork for further investigations of antibiotic prophylaxis regimens in shoulder arthroplasty. Because large randomized controlled trials would be impractical to perform, prospective register-based randomized controlled studies might be a viable method. LEVEL OF EVIDENCE Level Ⅲ, therapeutic study.
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Affiliation(s)
- Anne Dettmer
- Department of Biomedical and Clinical Science, Linköping University, Linköping, Sweden
- Department of Orthopaedics, Kalmar County Hospital, Kalmar, Sweden
| | - Marcus Melander
- Department of Clinical Science, Karolinska Institutet, Division of Orthopaedics, Danderyd Hospital, Stockholm, Sweden
| | - Hanna C. Björnsson Hallgren
- Department of Biomedical and Clinical Science, Linköping University, Linköping, Sweden
- Department of Orthopaedics, Linköping University Hospital, Linköping, Sweden
| | - Lars E. Adolfsson
- Department of Orthopaedics, Linköping University Hospital, Linköping, Sweden
- Department of Orthopaedics, Örebro University, Örebro, Sweden
| | - Björn Salomonsson
- Department of Clinical Science, Karolinska Institutet, Division of Orthopaedics, Danderyd Hospital, Stockholm, Sweden
- Division of Orthopaedics, Danderyd Hospital, Stockholm, Sweden
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Skedros JG, Finlinson ED, Luczak MG, Cronin JT. Septic Olecranon Bursitis With Osteomyelitis Attributed to Cutibacterium acnes: Case Report and Literature Overview of the Dilemma of Potential Contaminants and False-Positives. Cureus 2023; 15:e34563. [PMID: 36879721 PMCID: PMC9985484 DOI: 10.7759/cureus.34563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
We report an unusual case of acute septic olecranon bursitis, with probable olecranon osteomyelitis, where the only organism isolated in culture was initially considered a contaminant, Cutibacterium acnes. However, we ultimately considered it the likely causal organism when treatment for most of the other more likely organisms failed. This typically indolent organism is prevalent in pilosebaceous glands, which are scarce in the posterior elbow region. This case illustrates the often challenging empirical management of a musculoskeletal infection when the only organism isolated might be a contaminant, but successful eradication requires continued treatment as if it is the causal organism. The patient is a Caucasian 53-year-old male who presented to our clinic with a second episode of septic bursitis at the same location. Four years prior, he had septic olecranon bursitis from methicillin-sensitive Staphylococcus aureus that was treated uneventfully with one surgical debridement and a one-week course of antibiotics. In the current episode reported here, he sustained a minor abrasion. Cultures were obtained five separate times because of no growth and difficulty eradicating the infection. One culture grew C. acnes on day 21 of incubation; this long duration has been reported. The first several weeks of antibiotic treatment failed to eradicate the infection, which we ultimately attributed to inadequate treatment of C. acnes osteomyelitis. Although C. acnes has a well-known propensity for false-positive cultures as typically reported in post-operative shoulder infections, treatment for our patient's olecranon bursitis/osteomyelitis was successful only after several surgical debridements and a prolonged course of intravenous and oral antibiotics that targeted it as the presumptive causal organism. However, it was possible that C. acnes was a contaminant/superinfection, and another organism was the culprit, such as a Streptococcus or Mycobacterium species that was eradicated by the treatment regime targeted for C. acnes.
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Affiliation(s)
- John G Skedros
- Shoulder and Elbow, Utah Orthopaedic Specialists, Salt Lake City, USA.,Department of Orthopaedics, University of Utah, Salt Lake City, USA
| | - Ethan D Finlinson
- Shoulder and Elbow, Utah Orthopaedic Specialists, Salt Lake City, USA
| | - Meredith G Luczak
- Shoulder and Elbow, Utah Orthopaedic Specialists, Salt Lake City, USA
| | - John T Cronin
- Shoulder and Elbow, Utah Orthopaedic Specialists, Salt Lake City, USA
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Prat M, Guenezan J, Drugeon B, Burucoa C, Mimoz O, Pichon M. Impact of Skin Disinfection on Cutaneous Microbiota, before and after Peripheral Venous Catheter Insertion. Antibiotics (Basel) 2022; 11:antibiotics11091209. [PMID: 36139988 PMCID: PMC9495181 DOI: 10.3390/antibiotics11091209] [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: 07/20/2022] [Revised: 08/25/2022] [Accepted: 09/05/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction. Patients with invasive medical devices are at high risk for infection. Skin colonization is the initial stage of these infections, leading to the recommendation of practices requiring disinfection using antiseptics. Microbial communities playing a major role in skin health could be impacted by antiseptic procedures. Aim. To characterize and compare the bacterial communities of skin samples from patients before an antisepsis procedure, and after removal of the medical device itself, according to the nature of the antiseptic molecule (povidone iodine or chlorhexidine). Methods. The study focused on alterations in bacterial communities depending on the nature of the antiseptic procedure and type of intravascular device. After amplification of 16S rDNA, libraries (n = 498 samples) were sequenced using MiSeq platform. Results. Using an in-house pipeline (QIIME2 modules), while no alteration in skin microbiota diversity was associated with antiseptic procedure or PVC type, according to culture results (p < 0.05), alterations were at times associated with restricted diversity and higher dissimilarity (p < 0.05). Antiseptic procedures and PVC types were associated with the modification of specific bacterial representations with modulation of the Bacillota/Bacteroidota (Firmicutes/Bacteroidetes) ratio (modulation of C. acnes, Prevotella, Lagierella, and Actinomyces spp.) (p < 0.05). At baseline, the microbiota shows certain bacteria that are significantly associated with future PVC colonization and/or bacteremia (p < 0.05). All of these modulations were associated with altered expression of metabolic pathways (p < 0.05). Discussion. Finally, this work highlights the need to optimize the management of patients requiring intravascular devices, possibly by modulating the skin microbiota.
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Affiliation(s)
- Manon Prat
- CHU Poitiers, Bacteriology Laboratory, Infectious Agents Department, 86021 Poitiers, France
- INSERM U1070, Pharmacology of Antimicrobial Agents and Antibiotic Resistance, University of Poitiers, 86073 Poitiers, France
| | - Jeremy Guenezan
- INSERM U1070, Pharmacology of Antimicrobial Agents and Antibiotic Resistance, University of Poitiers, 86073 Poitiers, France
- CHU Poitiers, Emergency Room Department, 86021 Poitiers, France
| | - Bertrand Drugeon
- INSERM U1070, Pharmacology of Antimicrobial Agents and Antibiotic Resistance, University of Poitiers, 86073 Poitiers, France
| | - Christophe Burucoa
- CHU Poitiers, Bacteriology Laboratory, Infectious Agents Department, 86021 Poitiers, France
- INSERM U1070, Pharmacology of Antimicrobial Agents and Antibiotic Resistance, University of Poitiers, 86073 Poitiers, France
| | - Olivier Mimoz
- INSERM U1070, Pharmacology of Antimicrobial Agents and Antibiotic Resistance, University of Poitiers, 86073 Poitiers, France
- CHU Poitiers, Emergency Room Department, 86021 Poitiers, France
| | - Maxime Pichon
- INSERM U1070, Pharmacology of Antimicrobial Agents and Antibiotic Resistance, University of Poitiers, 86073 Poitiers, France
- CHU Poitiers, Emergency Room Department, 86021 Poitiers, France
- Correspondence: ; Tel.: +33-(0)5-4944-4143
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Wellington IJ, Schneider TJ, Hawthorne BC, McCarthy MB, Stelzer JW, Connors JP, Dorsey C, Williams V, Lindsay A, Solovyova O. Prevalence of Bacterial Burden on Macroscopic Contaminants of Orthopaedic Surgical Instruments Following Sterilization. J Hosp Infect 2022; 130:52-55. [PMID: 36087803 DOI: 10.1016/j.jhin.2022.08.010] [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: 08/07/2022] [Revised: 08/23/2022] [Accepted: 08/30/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Macroscopic contamination of orthopaedic instruments with particulates, including cortical bone and polymethyl methacrylate (PMMA) cement, having previously undergone preoperative sterilization, is frequently encountered peri- or intraoperatively, calling into question the sterility of such instruments. AIM The purpose of this study is to determine if macroscopic contaminants of orthopaedic surgical instrumentation maintain a bacterial burden following sterile processing. Additionally, this manuscript looks to determine the most commonly contaminated instruments and what the most common contaminants are. METHODS At a single tertiary referral centre, we prospectively collected available macroscopic contaminants in orthopaedic instrument trays over a six month period from August 2021 to May 2022. When identified, these specimens were swabbed and plated on sheep blood agar. All specimens were incubated at 37°C for 14 days, and visually inspected for colony formation. When bacterial colony formation was identified, samples were sent for species identification. RESULTS A total of 33 contaminants were tested, with only one contaminant growing bacterial colonies which was found to be Corynebacterium. The items most commonly found to have macroscopic contamination were surgical trays (9) and cannulated drills. The identifiable contaminants were bone (10), PMMA bone cement (4), and hair (4). There were 11 macroscopic contaminants that were not identifiable. CONCLUSION This study found that 97% of macroscopic orthopaedic surgical instrument contaminants that underwent sterile processing did not possess a bacterial burden. Contaminants discovered during a procedure are likely to be sterile and do not pose a substantially increased risk of infection to a patient.
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Affiliation(s)
- Ian J Wellington
- University of Connecticut Department of Orthopedics, 120 Dowling Way, Farmington, CT, 06032.
| | - Thomas J Schneider
- University of Connecticut Department of Orthopedics, 120 Dowling Way, Farmington, CT, 06032
| | - Benjamin C Hawthorne
- University of Connecticut Department of Orthopedics, 120 Dowling Way, Farmington, CT, 06032
| | - Mary Beth McCarthy
- University of Connecticut Department of Orthopedics, 120 Dowling Way, Farmington, CT, 06032
| | - John W Stelzer
- University of Connecticut Department of Orthopedics, 120 Dowling Way, Farmington, CT, 06032
| | - John P Connors
- University of Connecticut Department of Orthopedics, 120 Dowling Way, Farmington, CT, 06032
| | - Caitlin Dorsey
- University of Connecticut Department of Orthopedics, 120 Dowling Way, Farmington, CT, 06032
| | - Vincent Williams
- University of Connecticut Department of Orthopedics, 120 Dowling Way, Farmington, CT, 06032
| | - Adam Lindsay
- University of Connecticut Department of Orthopedics, 120 Dowling Way, Farmington, CT, 06032
| | - Olga Solovyova
- University of Connecticut Department of Orthopedics, 120 Dowling Way, Farmington, CT, 06032
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Marigi EM, Bartels DW, Yoon JH, Sperling JW, Sanchez-Sotelo J. Antibiotic Prophylaxis with Cefazolin Is Associated with Lower Shoulder Periprosthetic Joint Infection Rates Than Non-Cefazolin Alternatives. J Bone Joint Surg Am 2022; 104:872-880. [PMID: 35188900 DOI: 10.2106/jbjs.21.00445] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although prophylactic antibiotics are considered the standard of care, data with regard to the comparative efficacy of specific antibiotics in the prevention of periprosthetic joint infection (PJI) have remained limited. This study evaluated whether perioperative antibiotic choice affects rates of PJI development in shoulder arthroplasty. METHODS From 2000 to 2019, all primary shoulder arthroplasty types (hemiarthroplasty, anatomic total shoulder arthroplasty, reverse shoulder arthroplasty) performed for elective and trauma indications with perioperative antibiotic data and a minimum follow-up of 2 years were identified from a single institution. Demographic characteristics, PJI risk factors, and PJI-free survivorship data were retrieved. Multivariable analyses were conducted to determine the association between the antibiotic administered and the development of PJI. RESULTS Of 7,713 shoulder arthroplasties, cefazolin was administered in 6,879 procedures (89.2%) and non-cefazolin antibiotics consisting of vancomycin (465 procedures [6.0%]), clindamycin (345 procedures [4.5%]), and alternative regimens (24 procedures [0.31%]) were administered in 834 procedures (10.8%). PJIs occurred in 101 shoulder arthroplasties (1.3%), with Cutibacterium acnes as the most common pathogen (44 procedures [43.6%]). PJI-free survivorship was greater in shoulder arthroplasties in which cefazolin was administered compared with those in which non-cefazolin antibiotics were administered, with 0.91% greater survival free of PJI at 1 month, 1.4% at 1 year, and 2.7% at 15 years (p < 0.001). Cefazolin administration, compared with non-cefazolin administration, was associated with a 69% reduction in all-cause PJI risk and a 78% reduction in C. acnes PJI risk (p < 0.001). A higher risk of PJI for both groups was observed with vancomycin; the hazard ratio [HR] was 2.32 (95% confidence interval [CI], 1.22 to 4.40; p = 0.010) for all-cause PJI and 2.94 (95% CI, 1.12 to 7.49; p = 0.028) for C. acnes PJI. A higher risk of PJI was also observed for both groups for clindamycin; the HR was 5.07 (95% CI, 2.83 to 9.05; p < 0.001) for all-cause PJI and 8.01 (95% CI, 3.63 to 17.42; p < 0.001) for C. acnes PJI. CONCLUSIONS In primary shoulder arthroplasty, cefazolin administration was associated with a significantly lower rate of PJI compared with non-cefazolin alternatives, including both vancomycin and clindamycin. These risk discrepancies were observed across all infectious pathogens and may be considered even greater when C. acnes was the infecting bacterium. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Erick M Marigi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Joo Hee Yoon
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, Minnesota
| | - John W Sperling
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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11
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Ritter L, Bergoza L, Possa E, Tasso L. Is clindamycin a potential treatment for prostatitis? APMIS 2022; 130:197-205. [PMID: 34978745 DOI: 10.1111/apm.13205] [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: 07/09/2021] [Accepted: 01/02/2022] [Indexed: 11/29/2022]
Abstract
Cutibacterium acnes has been associated with chronic prostatitis, which can potentially favor the appearance of tumors in the prostate. Prostatitis is difficult to treat, and the drug needs to be able to penetrate the prostate. The aim was to investigate the pharmacokinetics of clindamycin in the interstitial fluid of rat prostate using microdialysis. Microdialysis probes were recovered in vitro and in vivo. Clindamycin was administered at 80 mg/kg iv bolus for plasma and tissue pharmacokinetic experiments. A microdialysis probe was implanted in the prostate gland for collections over an 8-hour period. The pharmacokinetic parameters were determined by both compartmental and non-compartmental approaches. Penetration was determined as the ratio between the area under the curve and the time of the clindamycin measurement in the prostate. The recovery of the in vivo probes was 38.11 ± 1.14%. The plasma profile was modeled by a two-compartment pharmacokinetic model. Clindamycin presented a prostate/plasma ratio of 1.02, with free concentrations above the minimum inhibitory concentration for Cutibacterium acnes isolates. This was the first study that determined clindamycin free concentrations in the prostatic fluid of rats. These findings suggest that clindamycin may be an effective alternative for the treatment of prostatitis caused by Cutibacterium acnes.
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Affiliation(s)
- Lisiani Ritter
- College of Pharmacy, University of Caxias do Sul, Caxias do Sul, Rio Grande do Sul, Brazil
| | - Larissa Bergoza
- College of Pharmacy, University of Caxias do Sul, Caxias do Sul, Rio Grande do Sul, Brazil
| | - Eduarda Possa
- College of Pharmacy, University of Caxias do Sul, Caxias do Sul, Rio Grande do Sul, Brazil
| | - Leandro Tasso
- College of Pharmacy, University of Caxias do Sul, Caxias do Sul, Rio Grande do Sul, Brazil.,Laboratory of Pharmacokinetics, Health Sciences Postgraduate Program and Biotechnology Postgraduate Program, University of Caxias do Sul, Caxias do Sul, Rio Grande do Sul, Brazil
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12
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Sandström N, Magnusson A, Wickbom A, Friberg Ö. Addition of benzylpenicillin to antibiotic prophylaxis reduces deep sternal wound infection after cardiac surgery. Infect Prev Pract 2021; 3:100161. [PMID: 34647011 PMCID: PMC8498681 DOI: 10.1016/j.infpip.2021.100161] [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: 04/29/2021] [Accepted: 07/13/2021] [Indexed: 12/03/2022] Open
Abstract
Objectives In Sweden, cloxacillin is recommended as the sole antibiotic prophylaxis for prevention of surgical site infections after cardiac surgery. Cutibacterium acnes, formerly Propionibacterium acnes, has been shown to be present in the surgical wound. Formerly an overlooked pathogen, there are increasing reports that C acnes can cause surgical site infections, including sternal wound infections. Cloxacillin may not be optimal for prevention of C acnes infection, therefore benzylpenicillin was added to our routine intraoperative prophylaxis in 2015. The aim of this study was to investigate the effect of benzylpenicillin on incidence of sternal wound infection. Methods We included 3920 consecutive patients that underwent cardiac surgery via median sternotomy at our centre from 2009 thru 2018. All patients were followed up two months postoperatively. The rate of sternal wound infection before and after 2015 were compared. Logistic multivariable analysis was used to adjust for potential confounders. Results The mean incidence of sternal wound infection that required surgical revision decreased from 4.7% to 1.7% after addition of benzylpenicillin (p < 0.001). Significant decrease was seen in sternal wound infections caused by Coagulase negative staphylococci, either alone (p<0.001) or concomitant with C acnes (p=0.008). Addition of benzylpenicillin remained independently associated with the reduction of sternal wound infections in the multivariable analysis (OR=0.36 CI=0.23–0.56, p<0.001). Conclusions Addition of benzylpenicillin was associated with a reduction in surgically treated infections and might be effective against infection caused by CoNS with and without co-infection by C acnes, although the exact underlying mechanism is unknown.
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Affiliation(s)
- Nadia Sandström
- Dept of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Anders Magnusson
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Anders Wickbom
- Dept of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Örjan Friberg
- Dept of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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13
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Paul YWL, Raghavan R, Dishish OMHE, Kiang ALC. Cutibacterium acnes Infection of Hip Bipolar Hemiarthroplasty Resulting in Protrusio Acetabuli: A Case Report and Review of Literature. J Orthop Case Rep 2021; 11:33-37. [PMID: 35415163 PMCID: PMC8930365 DOI: 10.13107/jocr.2021.v11.i09.2404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 05/07/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Hip bipolar hemiarthroplasty is commonly done for elderly patients who suffer from femoral neck fractures, with good functional outcomes. Prosthetic acetabular protrusio is a rare complication following bipolar hemiarthroplasty and can occur in prosthetic joint infections (PJIs) due to destructive osteolysis and resorption of surrounding bone. Among PJI pathogens, Cutibacterium acnes is increasingly being implicated. In our paper, we review the current literature of C. acnes PJIs and report a unique case of C. acnes infection of hip bipolar hemiarthroplasty complicated by protrusio acetabuli. CASE REPORT The patient is a 77-year-old Asian-Chinese man who suffered from left hip pain 10 years after bipolar hemiarthroplasty surgery. Radiographic evaluation showed acetabular protrusio with extensive femoral osteolysis. Subsequent intraoperative cultures revealed C. acnes infection. The patient successfully underwent antibiotic treatment and a two-staged revision total hip arthroplasty. CONCLUSION C. acnes is an increasingly recognized cause of PJIs and can cause significant morbidity. It should not be simply regarded as a contaminant of tissue or cultures. C. acnes PJIs require antibiotic treatment and early surgery with debridement and revision. This reported case presented technical challenges due to the infection resulting in prosthetic acetabular protrusio.
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Affiliation(s)
- Yuen Wen Loong Paul
- Department of Orthopaedic Surgery, Changi General Hospital, Singapore,Address of Correspondence: Dr. Yuen Wen Loong Paul, Department of Orthopaedic Surgery, Changi General Hospital, Singapore. E-mail:
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14
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Li L, Wang Y, Wang S. Efficacy comparison of chlorhexidine and iodine preparation in reduction of surgical site infection: A systemic review and meta-analysis. Int J Nurs Stud 2021; 127:104059. [PMID: 35121520 DOI: 10.1016/j.ijnurstu.2021.104059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 07/28/2021] [Accepted: 08/02/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Chlorhexidine and povidone-iodine are the most common disinfectants used in preoperative skin preparation. However, there is no consistent conclusion regarding the prevention of surgical site infection (SSI) and bacterial culture data. OBJECTIVE To assess the efficacy of chlorhexidine and povidone-iodine in the prevention of postoperative SSI and relevant bacterial data. DESIGN Systematic Review and Meta-Analysis SETTINGS: N/A PARTICIPANTS: N/A METHOD: Literature relevant to "skin antisepsis" and "surgical site infections" was retrieved from PUBMED, Web of Science, EMBASE, CINHAL and CNKI. The incidence of SSI was the primary outcome, while the secondary outcome was bacterial data from the infected incision. All data were analyzed with Revman 5.3 and Stata Statistical Software. RESULTS A total of 36 studies were identified in this study, which included 16,872 participants. This study revealed that chlorhexidine is superior to povidone-iodine in the prevention of postoperative SSI (risk ratio [RR], 0.73; 95% confidence interval [CI], 0.61-0.87; p = 0.019, I2 = 39%). Further meta-regression analysis revealed that the effect of chlorhexidine was directly associated with the type of incision, but failed to differentiate between the subgroups divided according to the type of incision. With respect to bacteria colonization, the most common bacteria for chlorhexidine arm were propionibacterium's, while the most common bacteria for the iodine arm were staphylococci species. CONCLUSION In comparison to povidone-iodine, chlorhexidine showed better results in preventing postoperative SSI.
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Affiliation(s)
- Li Li
- Clean Operating department, Harbin Medical University Cancer Hospital, Harbin City, Heilongjiang Province, China
| | - Yu Wang
- The Image Center, Harbin Medical University Cancer Hospital, Harbin City, Heilongjiang Province, China.
| | - Shouyan Wang
- Clean Operating department, Harbin Medical University Cancer Hospital, Harbin City, Heilongjiang Province, China
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15
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Abdelhamid AA, Kobayashi T, Tholany J, Sekar P. Recurrent Cutibacterium acnes prosthetic valve endocarditis. BMJ Case Rep 2021; 14:14/7/e243878. [PMID: 34326116 PMCID: PMC8323374 DOI: 10.1136/bcr-2021-243878] [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: 11/03/2022] Open
Abstract
A 29-year-old man with a history of congenital aortic stenosis and mechanical aortic valve replacement with previous Cutibacterium acnes prosthetic valve endocarditis (PVE) presented with a 2-week history of fevers and night sweats. Transoesophageal echocardiogram revealed a 0.6 cm×0.5 cm vegetation on the mechanical aortic valve. An anaerobic blood culture became positive for C. acnes 6 days after the blood cultures were obtained. He did not have any surgical intervention. He was successfully treated with 6 weeks of ceftriaxone, followed by chronic suppression with oral doxycycline. Despite its low virulence, a growing number of C. acnes PVE cases have been reported, owing to its biofilm production. When clinical suspicion is high, extending culture incubation duration beyond the standard 5 days might be helpful. Most cases are treated with surgical repair or replacement in conjunction with antibiotics, but medical therapy alone has been documented as being successful.
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Affiliation(s)
| | - Takaaki Kobayashi
- Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Joseph Tholany
- Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Poorani Sekar
- Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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16
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Henry TW, Entezari V, Ghoraishian M, Williams GR, Namdari S. Complications Associated With Intravenous Antibiotic Treatment for Cutibacterium acnes Periprosthetic Shoulder Infection. Orthopedics 2021; 44:e422-e426. [PMID: 34039208 DOI: 10.3928/01477447-20210414-17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Whether positive Cutibacterium acnes cultures during revision shoulder arthroplasty represent true periprosthetic joint infection (PJI), deep tissue inoculant, or laboratory contaminant is a point of substantial controversy. The purpose of this study was to review complications of intravenous antibiotics used for treatment of presumed C acnes shoulder PJI. A study population of 26 patients treated for C acnes PJI with a minimum follow-up of 2 years after operative treatment was established. Complication occurrence and severity were obtained through chart review and phone survey. Sixteen (61.5%) patients experienced a therapeutic complication. Twelve (46.2%) patients experienced a total of 47 antibiotic-associated adverse effects and 10 (38.5%) patients experienced 11 total peripherally inserted central catheter line-associated complications. Female sex carried an increased risk for severe complications (relative risk, 3.3; 95% CI, 1.2-9.5; P=.024). Treatment duration of greater than 6 weeks was a significant predictor for the total number of complications experienced [F(1,23)=5.361; P=.030; adjusted R2=0.189]. Age older than 65 years, treatment duration greater than 6 weeks, and female sex were significant predictors for the number of severe complications [F(3,21)=3.249; P=.042; adjusted R2=0.219]. Treating C acnes infection with intravenous antibiotics carries a substantial risk of adverse events, highlighting the importance of accurate diagnosis of shoulder PJI. Further investigations into the efficacy and safety profile of oral antibiotics for shoulder PJI are necessary. [Orthopedics. 2021;44(3):e422-e426.].
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17
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Tiltnes TS, Kehrer M, Hughes H, Morris TE, Justesen US. Ceftriaxone treatment of spondylodiscitis and other serious infections with Cutibacterium acnes. J Antimicrob Chemother 2021; 75:3046-3048. [PMID: 32591800 DOI: 10.1093/jac/dkaa259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/14/2020] [Accepted: 05/15/2020] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES To establish testing and treatment recommendations for a ceftriaxone once-daily dose regimen for systemic infections with Cutibacterium acnes. METHODS A review of the literature and a retrospective evaluation of patients diagnosed with C. acnes spondylodiscitis and treated with ceftriaxone were performed. Ceftriaxone and penicillin MICs were determined for C. acnes isolates from blood and biopsies and the epidemiological cut-off (ECOFF) was determined with surveillance data from the UK Anaerobe Reference Laboratory in Cardiff. RESULTS Limited clinical data exist from endocarditis and prosthetic joint infections using treatment with ceftriaxone 2 g once daily for C. acnes with ceftriaxone MICs ≤0.5 mg/L. In this case study, five patients were successfully treated with ceftriaxone as part of the treatment for spondylodiscitis with C. acnes. Ceftriaxone and penicillin MICs of the C. acnes isolates from the patients were 0.016-0.125 mg/L and 0.012-0.032 mg/L, respectively. The ceftriaxone ECOFF was 0.5 mg/L and the penicillin ECOFF was 0.25 mg/L based on available surveillance data. CONCLUSIONS From the data presented in this study it would be acceptable to consider treatment with a once-daily dose of ceftriaxone 2 g for systemic infections, including endocarditis, spondylodiscitis and prosthetic joint infections with C. acnes using a clinical breakpoint of ≤0.5 mg/L (the ECOFF). However, clinical data are still limited and the response of patients treated with ceftriaxone for serious infections with C. acnes should be monitored closely.
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Affiliation(s)
- Theo S Tiltnes
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
| | - Michala Kehrer
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
| | - Harriet Hughes
- UK Anaerobe Reference Unit (UKARU), Public Health Wales Microbiology Cardiff, University Hospital of Wales, Cardiff, Wales
| | - Trefor E Morris
- UK Anaerobe Reference Unit (UKARU), Public Health Wales Microbiology Cardiff, University Hospital of Wales, Cardiff, Wales
| | - Ulrik S Justesen
- Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark
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18
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Gilligan CJ, Cohen SP, Fischetti VA, Hirsch JA, Czaplewski LG. Chronic low back pain, bacterial infection and treatment with antibiotics. Spine J 2021; 21:903-914. [PMID: 33610802 DOI: 10.1016/j.spinee.2021.02.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 02/14/2021] [Accepted: 02/15/2021] [Indexed: 02/03/2023]
Abstract
The contribution of bacterial infection to chronic low back pain and its treatment with antibiotics have generated considerable controversy in literature. If efficacious, antibiotics have the potential to transform the treatment of chronic low back pain in a significant subset of patients. Some microbiology studies of disc tissue from patients with CLBP have shown that bacteria are present, most likely due to infection, while others conclude they are absent or if found, it is due to surgical contamination. Clinical studies testing the efficacy of oral antibiotics to treat CLBP have either shown that the treatment is efficacious leading to significantly reduced pain and disability or that their effect is modest and not clinically significant. Critical review of the literature on CLBP, bacterial infection and treatment with antibiotics identified five well-designed and executed microbiology studies characterizing bacteria in disc samples that demonstrate that bacteria do infect herniated disc tissue, but that the bacterial burden is low and may be below the limits of detection in some studies. Two randomized, controlled clinical trials evaluating oral antibiotics in patients with CLBP indicate that for certain subsets of patients, the reduction in pain and disability achieved with antibiotic therapy may be significant. In patients for whom other therapies have failed, and who might otherwise progress to disc replacement or fusion surgery, antibiotic therapy may well be an attractive option to reduce the individual suffering associated with this debilitating condition. Additional clinical research is recommended to refine the selection of patients with CLBP caused or complicated by bacterial infection and most likely to respond to antibiotics, to optimize antibiotic therapy to maximize patient benefit, to minimize and manage side effects, and to address legitimate concerns about antibiotic stewardship.
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Affiliation(s)
- Christopher J Gilligan
- Brigham and Women's Hospital, Department of Anesthesiology, Perioperative and Pain Medicine, Boston, MA, USA
| | - Steven P Cohen
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 550 N. Broadway, Ste 301, Baltimore, MD 21029, USA; Department of Anesthesiology, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889, USA
| | - Vincent A Fischetti
- Laboratory of Bacterial Pathogenesis and Immunology, The Rockefeller University, New York, New York
| | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Lloyd G Czaplewski
- Persica Pharmaceuticals Ltd, 7 Denne Hill Business Centre, Womenswold, Canterbury, Kent, CT4 6HD, UK.
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Foster AL, Cutbush K, Ezure Y, Schuetz MA, Crawford R, Paterson DL. Cutibacterium acnes in shoulder surgery: a scoping review of strategies for prevention, diagnosis, and treatment. J Shoulder Elbow Surg 2021; 30:1410-1422. [PMID: 33373684 DOI: 10.1016/j.jse.2020.11.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 11/02/2020] [Accepted: 11/08/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Cutibacterium acnes is a commensal, gram-positive, facultatively anaerobic bacillus that resides in the dermis. Historically thought to be a contaminant when identified on cultured specimens, recent advances in diagnostic technology have now implicated it as the most common organism responsible for postoperative shoulder infections. Despite a recognition of the role of this organism and a significant research interest in recent years, there is clear lack of consensus guideline on strategies to prevent, diagnose, and treat postoperative shoulder infection. METHOD The electronic databases PubMed, MEDLINE, CINAHL, Scopus, and Web of Science were searched in March 2020. All experimental and nonexperimental studies that investigate C acnes in shoulder surgery were included. Inclusion was limited to articles published after 2000 and written in English; reviews, gray literature, or abstracts were excluded. A total of 70 studies were included in this review. This scoping review was performed in accordance with the Extended Preferred Reporting Items of Systematic Reviews and Meta-Analyses Statement for Scoping Reviews (PRISMA-ScR). RESULTS Standard surgical prophylactic regimens such as intravenous antibiotics and topical chlorhexidine are ineffective at removing C acnes from the deep layer of the dermis, and there is a shift toward using topical benzoyl peroxide with significantly improved efficacy. An improved understanding of the bacteria has demonstrated that a prolonged culture time of up to 14 days is needed, especially in cases of established infection. Advances in diagnostics such as sonication and molecular-based testing are promising. Although usually thought to be susceptible to a broad range of antibiotics, resistance is emerging to clindamycin. An improved understanding of its ability to form a biofilm highlights the difficulty in treating an established infection. CONCLUSION The role of C acnes causing postoperative infection following shoulder surgery is being increasingly recognized. Strategies for prevention, diagnosis, and treatment have been outlined from both an antimicrobial and surgical perspective. A number of these strategies are emerging and require further research to demonstrate efficacy before implementation into clinical guidelines.
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Affiliation(s)
- Andrew L Foster
- Faculty of Science and Engineering, Queensland University of Technology (QUT), Brisbane, QLD, Australia; Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Herston, QLD, Australia; Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, QLD, Australia; Department of Surgery, School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Kenneth Cutbush
- Faculty of Science and Engineering, Queensland University of Technology (QUT), Brisbane, QLD, Australia; Department of Surgery, School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Yukiko Ezure
- University of Queensland Centre for Clinical Research, RBWH Campus, Brisbane, QLD, Australia
| | - Michael A Schuetz
- Faculty of Science and Engineering, Queensland University of Technology (QUT), Brisbane, QLD, Australia; Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Herston, QLD, Australia; Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Ross Crawford
- Faculty of Science and Engineering, Queensland University of Technology (QUT), Brisbane, QLD, Australia
| | - David L Paterson
- University of Queensland Centre for Clinical Research, RBWH Campus, Brisbane, QLD, Australia.
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20
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Yadav AK, Bhooshan S, Johnson A, Asati DP, Nema S, Biswas D. Association of Antimicrobial Susceptibility and Treatment Outcome in Acne Vulgaris Patients: A Pilot Study. J Lab Physicians 2021; 12:233-238. [PMID: 33469248 PMCID: PMC7808859 DOI: 10.1055/s-0040-1720943] [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] [Indexed: 11/11/2022] Open
Abstract
Purpose
Cutibacterium acnes
(
C. acnes
) is an emerging pathogen that is highly resistant to antibiotics and is capable of causing persistent infections that are difficult to treat.
Methods & Materials
Acne vulgaris patients visiting dermatology OPD of our tertiary care hospital during the study period of 2 months were recruited. Skin swabs were collected, and the sample was processed on 5% sheep-blood agar for anaerobic culture by the GasPak method. Isolates were identified by the standard biochemical test. Antimicrobial susceptibility testing was performed for clinically relevant antibiotics by the E-strip method. The clinical response was evaluated after 1-month follow-up to the prescribed antibiotics.
Results
Minocycline, doxycycline, ceftriaxone, and tetracycline were the most effective antibiotics. Nonsusceptibility to clindamycin and erythromycin were observed in 11.9% and 31% isolates, respectively, with 9.5% isolates being nonsusceptible to both. For none of the antibiotics we found significant difference in the proportion of susceptible and nonsusceptible isolates between mild, moderate, and severe grades of acne vulgaris. For none of the antibiotic regimens, significant difference was observed between nonresponders and responders. Twenty-seven patients received clindamycin and among them 16 of 19 responders and 6 of 8 nonresponders yielded growth of clindamycin-susceptible isolates (
p
= 0.57).
Conclusion
We observed significant prevalence of resistant strains of
C. acnes
among patients with acne vulgaris. No association was observed between in vitro susceptibility results and treatment outcome.
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Affiliation(s)
- Ashvini K Yadav
- Department of Microbiology, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
| | - Suneel Bhooshan
- Department of Microbiology, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
| | - Allen Johnson
- Department of Microbiology, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
| | - Dinesh P Asati
- Department of Dermatology, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
| | - Shashwati Nema
- Department of Microbiology, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
| | - Debasis Biswas
- Department of Microbiology, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
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21
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Fowler BJ, Miller D, Yan X, Yannuzzi NA, Flynn HW. Postoperative Endophthalmitis Caused by Cutibacterium (Formerly Propionibacterium) Acnes: Case Series and Review. Case Rep Ophthalmol 2021; 12:1-10. [PMID: 33613244 PMCID: PMC7879283 DOI: 10.1159/000510208] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 07/10/2020] [Indexed: 11/22/2022] Open
Abstract
We report the clinical features, treatment strategies and outcomes in a series of patients with infectious endophthalmitis after cataract surgery caused by Cutibacterium acnes (C. acnes), formerly known as Propionibacterium acnes (P. acnes). This retrospective case series includes six eyes of six patients with chronic postoperative endophthalmitis caused by culture-proven C. acnesfrom December 2010 to July 2019 at a University referral center. All patients underwent prior cataract extraction with intraocular lens (CE/IOL) implantation. The mean time between cataract surgery and the microbiologic diagnosis of endophthalmitis was 7.4 ± 5.2 months (range 1.5–17 months). The average time from obtaining the specimen to culture positivity was 7.7 ± 4.4 days (range 3–15 days). Three eyes (50%) presented with hypopyon and three eyes (50%) presented with prominent keratic precipitates without hypopyon. Presenting visual acuity ranged from 20/25 to 2/200. Initial treatments included intravitreal antibiotics alone (n = 2), pars plana vitrectomy (PPV) with partial capsulectomy and intravitreal antibiotics (n = 3), and pars plana vitrectomy with IOL removal and intravitreal antibiotics (n = 1). Follow-up treatments included IOL removal (n = 2), intravitreal antibiotics (n = 1), and topical antibiotics (n = 1). The best-corrected visual acuity at last follow-up was 20/70 or better in all patients. In a literature review, the clinical features and treatment outcomes for all case series of delayed-onset postoperative endophthalmitis caused by C. acnes(n = 120) are listed. A definitive cure (the absence of recurrent inflammation) was achieved in 100% of patients that underwent IOL removal, in 77% of those that underwent PPV/partial capsulectomy and intravitreal antibiotics, and in 18% of cases treated with intravitreal antibiotics alone. Endophthalmitis after CE/IOL caused by C. acnesis characterized by slowly progressive intraocular inflammation and has a protracted course from surgery to microbiologic diagnosis. Visual outcomes are generally favorable, but IOL explantation may be necessary for definitive cure.
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Affiliation(s)
- Benjamin J Fowler
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Darlene Miller
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Xiaohe Yan
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA.,Shenzhen Key Laboratory of Ophthalmology, Shenzhen Eye Hospital, Jinan University, Shenzhen, China
| | - Nicolas A Yannuzzi
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Harry W Flynn
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
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Is Patient-reported Penicillin Allergy Independently Associated with Increased Risk of Prosthetic Joint Infection After Total Joint Arthroplasty of the Hip, Knee, and Shoulder? Clin Orthop Relat Res 2020; 478:2699-2709. [PMID: 33027190 PMCID: PMC7899399 DOI: 10.1097/corr.0000000000001497] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patients with a patient-reported penicillin allergy may be at greater risk for postoperative prosthetic joint infection (PJI) after total joint arthroplasty of the hip, knee, or shoulder. The increased risk of PJI in these patients has been attributed to these patients receiving a less-effective perioperative antibiotic. However, prior reports did not fully address the clinical characteristics of these unique patients, who may inherently be at greater risk of having a PJI, which may confound prior findings. QUESTIONS/PURPOSES After controlling for risk factors for PJI such as BMI, anxiety, depression, and other comorbidities, we asked: Are patients with a patient-reported penicillin allergy more likely to have a PJI after THA, TKA, or total shoulder arthroplasty than patients without such a reported allergy? METHODS We queried patient records from 2010 to 2017 from a nationwide administrative claims database of 122 million patients to adequately power an investigation comparing the 1-year incidence of PJI after TKA, total shoulder arthroplasty, and THA in patients with patient-reported penicillin allergy versus patients without a patient-reported penicillin allergy. Operative treatments for deep joint infection, identified by Current Procedural Terminology and ICD-9 and ICD-10 codes were used as a surrogate for PJI. Clinical characteristics such as age, sex, BMI, length of stay, and Charlson comorbidity index and specific comorbidities including alcohol abuse, anemia, anxiety, cardiac disease, diabetes, immunocompromised status, rheumatoid arthritis, depression, liver disease, chronic kidney disease, tobacco use, and peripheral vascular disease were queried for each study group. The odds of PJI within 1 year of THA, TKA, or total shoulder arthroplasty were compared using multiple logistic regression after adjusting for potential confounders. RESULTS After adjusting for potential confounding factors such as BMI, anxiety, depression and other comorbidities, we found that patient-reported penicillin allergy was independently associated with an increased odds of PJI after TKA (odds ratio 1.3 [95% confidence interval 1.1 to 1.4]; p < 0.01) and total shoulder arthroplasty (OR 3.9 [95% CI 2.7 to 5.4]; p < 0.01). However, patient-reported penicillin allergy was not independently associated with an increased odds of PJI after THA (OR 1.1 [95% CI 0.9 to 1.3]; p = 0.36) after controlling for the same risk factors. CONCLUSIONS In this study, we found that patients with patient-reported penicillin allergy were at an increased risk for PJI after TKA and total shoulder arthroplasty, which we suspect-but cannot prove-is likely a function of those patients receiving a second-line antibiotic for presurgical prophylaxis. Since prior research has found that many patients listed in medical records as having a penicillin allergy are in fact not allergic to penicillin, we suggest that surgeons consider preoperative allergy testing, such as using an intraoperative test dose, to aid in choosing the most appropriate antibiotic choice before knee or shoulder arthroplasty and to amend patient medical records based on testing results. Future studies should determine whether this additional diagnostic maneuver is cost-effective. LEVEL OF EVIDENCE Level III, therapeutic study.
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Boyle KK, Marzullo BJ, Yergeau DA, Nodzo SR, Crane JK, Duquin TR. Pathogenic genetic variations of C. acnes are associated with clinically relevant orthopedic shoulder infections. J Orthop Res 2020; 38:2731-2739. [PMID: 32644213 DOI: 10.1002/jor.24798] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/22/2020] [Accepted: 06/24/2020] [Indexed: 02/04/2023]
Abstract
Many surgeons continue to face the clinical dilemma of interpreting a positive aspiration or unexpected positive Cutibacterium acnes (C. acnes) culture. There are factors that complicate the interpretation of positive cultures including variations in both frequency of false positive cultures and virulence properties. As indices of virulence, hemolytic strains, from previously confirmed clinically infected shoulders, were compared with non-hemolytic isolates determined to be contaminants, by RNA-sequencing (RNA-Seq). Six C. acnes isolates from patients who underwent revision total shoulder arthroplasty (TSA) were identified based on previously described infection criteria. Three C. acnes isolates from each group underwent RNA-Seq. Differential gene expression analysis, principal component analysis (PCA), and heatmap analysis were used to determine the gene variation and patterning between the definite infection and probable contaminant isolates. Differential gene expression analysis identified genes that were differentially expressed between the isolates classified as definite infection and isolates classified as probable contaminants. PCA using a 500 gene subset of identified genes was able to find combinations of these genes that separated out the definite infection and probable contaminants isolates. The heatmap demonstrated similar gene expression in the three Definite Infections isolates, and significantly different expression when compared with the probable contaminant isolates. Clinical significance: C. acnes revision TSA isolates classified as definite infection and probable contaminant demonstrated a similar gene expression pattern to each respective group and different gene expression pattern when compared between groups. These findings indicate distinct differences in C. acnes strains associated with clinically relevant orthopedic TSA infections.
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Affiliation(s)
- K Keely Boyle
- Department of Orthopaedics, State University of New York, Buffalo, New York
| | - Brandon J Marzullo
- Genomics and Bioinformatics Core, NYS Center of Excellence in Bioinformatics and Life Sciences (CBLS), State University of New York, Buffalo, New York
| | - Donald A Yergeau
- Genomics and Bioinformatics Core, NYS Center of Excellence in Bioinformatics and Life Sciences (CBLS), State University of New York, Buffalo, New York
| | - Scott R Nodzo
- Department of Orthopaedics, State University of New York, Buffalo, New York
| | - John K Crane
- Department of Infectious Disease, State University of New York, Buffalo, New York
| | - Thomas R Duquin
- Department of Orthopaedics, State University of New York, Buffalo, New York
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Antimicrobial Susceptibility Patterns and Wild-Type MIC Distributions of Anaerobic Bacteria at a German University Hospital: A Five-Year Retrospective Study (2015-2019). Antibiotics (Basel) 2020; 9:antibiotics9110823. [PMID: 33217968 PMCID: PMC7698766 DOI: 10.3390/antibiotics9110823] [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] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/11/2020] [Accepted: 11/16/2020] [Indexed: 12/23/2022] Open
Abstract
Local antimicrobial susceptibility surveys are crucial for optimal empirical therapy guidelines and for aiding in antibiotic stewardship and treatment decisions. For many laboratories, a comprehensive overview of local antimicrobial susceptibility patterns of anaerobic bacteria is still lacking due to the long incubation time and effort involved. The present study investigates the antimicrobial susceptibility patterns and related clinical and demographic data of 2856 clinical isolates of anaerobic bacteria that were submitted for analysis to the Institute for Medical Microbiology and Hygiene of the Freiburg University Medical Center (a tertiary university medical center in Southern Germany) between 2015 and 2019. Antimicrobial susceptibility testing has been carried out according to the European Committee on Antimicrobial Susceptibility Testing (EUCAST) guideline. Minimum inhibitory concentration (MIC)50 and MIC90 for penicillin, metronidazole, moxifloxacin, and clindamycin were established for Gram-positive anaerobes and for ampicillin-sulbactam, meropenem, metronidazole, moxifloxacin, and clindamycin for Gram-negative anaerobes. The distribution of MIC-values for various antibiotics against anaerobic bacteria was also established, especially for those having no specific breakpoints according to EUCAST guidelines. Most clinically relevant anaerobic bacteria originated from general surgery, neurological, and orthopedic wards. A high proportion of isolates were resistant to moxifloxacin and clindamycin indicating the importance of their susceptibility testing before administration. Based on our study metronidazole and other β-lactam/β-lactamase inhibitor combinations such as ampicillin-sulbactam remain suitable for empirical treatment of infections with anaerobic bacteria.
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Detection of Cutibacterium acnes in arthroscopic rotator cuff and bankart repair. J Orthop Sci 2020; 25:825-829. [PMID: 31784182 DOI: 10.1016/j.jos.2019.10.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 09/30/2019] [Accepted: 10/30/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND We evaluated the detection rate for Cutibacterium acnes (C. acnes) in patients who underwent arthroscopic cuff repair and Bankart repair. METHODS Arthroscopic cuff repair was performed in 105 patients (R group) and arthroscopic Bankart repair was performed in 29 patients (B group). Skin swabs prior to antisepsis, intraoperative synovial swabs of the glenohumeral joint (immediately after incision and prior to wound closure), suture of suture anchor, and postoperative swabs from the tip of arthroscope were cultured. Evaluation criteria were compared between groups and included the presence or absence of diabetes mellitus, operation time, frequency of preoperative injections, deep infections, and detection rate of C. acnes in multiple regions of the body. RESULTS There were 14 patients (12.2%) in the R group and one patient in the B group (3.6%) with diabetes mellitus, and no significant difference was found between the two groups. The frequency of injections to the shoulder was significantly greater in the R group at 3.6 ± 4.2 times compared to the B group at 1.6 ± 2.0 times. There were no deep infections in either groups. The detection rate for C. acnes was significantly greater in the synovial swabs alone (skin swabs for R and B groups, 42.3% and 47.6%, respectively; synovial swabs, 10.4% and 1.8%; suture, 8.7% and 0%; tip of arthroscope, 4.3% and 0%). CONCLUSIONS A significantly greater number of C. acnes samples were detected from synovial swabs of cuff tears, suggesting that its presence may be due to preoperative injections to the shoulder.
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Patel MS, Singh AM, Gregori P, Horneff JG, Namdari S, Lazarus MD. Cutibacterium acnes: a threat to shoulder surgery or an orthopedic red herring? J Shoulder Elbow Surg 2020; 29:1920-1927. [PMID: 32499199 DOI: 10.1016/j.jse.2020.02.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/10/2020] [Accepted: 02/20/2020] [Indexed: 02/01/2023]
Abstract
Cutibacterium acnes is a lipophilic, anaerobic, gram-positive bacillus that mainly colonizes the pilosebaceous glands of human skin. It has been implicated as the leading cause of prosthetic joint infection (PJI) after shoulder arthroplasty. However, PJI caused by C acnes rarely manifests as overt clinical, laboratory, or imaging features. In fact, more than 40% of shoulders undergoing revision arthroplasty are likely to be culture positive. However, rates of infection following a positive culture can be as low as 5%. The purpose of this review was to put forth alternative explanations for this discordance between positive cultures and infection. We describe C acnes roles as a commensal, bystander, and/or contaminant organism; the role of cultures in diagnosis and other methods that may be more accurate; its existence in a shoulder microbiome; and the variable virulence of C acnes. C acnes is an important cause of shoulder PJI in some patients. However, there is a large body of literature that suggests other functions that need to be considered. Further research is needed to define the role of C acnes that is logically explained by all of the literature and not only some.
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Affiliation(s)
- Manan S Patel
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA.
| | - Arjun M Singh
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Pietro Gregori
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - John G Horneff
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Surena Namdari
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Mark D Lazarus
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
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Nhan DT, Woodhead BM, Gilotra MN, Matsen FA, Hsu JE. Efficacy of Home Prophylactic Benzoyl Peroxide and Chlorhexidine in Shoulder Surgery: A Systematic Review and Meta-Analysis. JBJS Rev 2020; 8:e2000023. [PMID: 32796196 DOI: 10.2106/jbjs.rvw.20.00023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Two predominant prophylactic home skin-disinfection regimens exist in shoulder surgery, benzoyl peroxide and chlorhexidine. Of these 2 regimens, benzoyl peroxide gel is more effective than chlorhexidine in reducing the rate of positive Cutibacterium cultures on the skin surface. At present, there are no studies that assess the impact of these home prophylactic measures on clinical infection rates.
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Affiliation(s)
- Derek T Nhan
- Department of Orthopaedic Surgery and Sports Medicine, University of Washington, Seattle, Washington
| | | | - Mohit N Gilotra
- Department of Orthopaedics, University of Maryland, Baltimore, Maryland
| | - Frederick A Matsen
- Department of Orthopaedic Surgery and Sports Medicine, University of Washington, Seattle, Washington
| | - Jason E Hsu
- Department of Orthopaedic Surgery and Sports Medicine, University of Washington, Seattle, Washington
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28
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Bhargava S, Listopadzki T, Diletti S, Crane JK, Duquin TR, Boyle KK. Effect of Blue Light and Photosensitizers on Cutibacterium acnes on Shoulder Periprosthetic Joint Infection Isolates. J Bone Jt Infect 2020; 5:187-197. [PMID: 32670773 PMCID: PMC7358969 DOI: 10.7150/jbji.46199] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 05/01/2020] [Indexed: 11/22/2022] Open
Abstract
Introduction:Cutibacterium acnes is gaining recognition as a leading pathogen after orthopaedic shoulder procedures. Photodynamic therapy, a combination of light and a photosensitizer, has demonstrated antimicrobial activity against C. acnes in the treatment of acne vulgaris. We sought to evaluate the effect of photodynamic therapy using blue light and photosensitizers on C. acnes isolates from shoulder prosthetic joint infections. Methods:C. acnes strains isolated from 19 patients with shoulder PJI were exposed to blue light alone (415 nm) or in combination with photosensitizers (fluorescein, riboflavin and demeclocycline). C. acnes strains were divided into 4 categories: Highly Sensitive (HS), Sensitive (S), Weakly Sensitive (WS), Resistant to blue light. Results: 13 of 19 C. acnes strains (68%) were S or HS to blue light alone. Of these 19 strains tested, 11 were tested with blue light and fluorescein or blue light plus riboflavin. Fluorescein (1 µg/mL) enhanced the effect of blue light in 6 of 11 strains (55%). Blue light plus riboflavin (10 µg/mL) resulted enhanced killing in 3 of 11 strains (27%), but produced a paradoxical photoprotective effect in 4 of 11 strains (36%), resulting in a net decrease compared to blue light alone. Demeclocycline, however, enhanced the effect of blue light in 16 of 17 strains (94 %). Conclusions: Blue light with the addition of photosensitizers killed C. acnes from periprosthetic shoulder infections in vitro, with demeclocycline having the most pronounced effect.
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Affiliation(s)
- Swati Bhargava
- Department Medicine, Division of Infectious Disease, University at Buffalo, Buffalo, NY
| | - Thomas Listopadzki
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY
| | - Sara Diletti
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY
| | - John K Crane
- Department Medicine, Division of Infectious Disease, University at Buffalo, Buffalo, NY
| | - Thomas R Duquin
- Department of Orthopaedics, State University of New York at Buffalo, Buffalo, NY
| | - K Keely Boyle
- Department of Orthopaedics, State University of New York at Buffalo, Buffalo, NY
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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.
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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
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Caseris M, Ilharreborde B, Doit C, Simon AL, Vitoux C, Poey N, Bonacorsi S, Mallet C. Is Cutibacterium acnes early surgical site infection rate related to the duration of antibiotic prophylaxis in adolescent idiopathic scoliosis surgery? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:1499-1504. [PMID: 32342283 DOI: 10.1007/s00586-020-06427-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 04/01/2020] [Accepted: 04/15/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE Cutibacterium acnes (C. acnes) is a gram-positive anaerobic bacillus located in pilosebaceous glands, usually responsible for late postoperative surgical site infections (SSI). A recent study performed in our institution highlighted an unexpected emergence of C. acnes early SSI. One potential explanation was the change of the perioperative antibioprophylaxis (ATB) protocol, which switched from 48 h postoperative cefamandole to intraoperative only cefazoline. The aim of this study was therefore to investigate the influence of the ATB duration on the occurrence of C. acnes early SSI, by comparing the incidence rates during 3 consecutive ATB protocols. METHODS Between January 2007 and September 2017, all patients who underwent posterior fusion for AIS were retrospectively reviewed. Early C. acnes SSI were reported and compared between 3 periods, during which the ATB protocols were modified. January 2007-February 2012: Intraoperative Cefamandole continued 48 h (protocol 1) March 2012-August 2016: Single shot of intraoperative Cefazoline (protocol 2) September 2016-September 2017: Intraoperative Cefazoline continued 48 h (protocol 3). RESULTS Fifty-three early SSI (7.2%) were reported among the 732 posterior AIS fusions included. Global incidence of C. acnes infection was 2.9%. The incidence of C. acnes in early SSI increased from 0 to 4.9% between protocol 1 and 2, but was reduced to 1.7% with protocol 3. CONCLUSIONS Early C acnes SSI can be explained by the difficulty to eradicate this pathogen with current skin preparation procedures and some Beta-lactam antibiotics tolerance. Longer duration antibioprophylaxis is preferable to prevent from early C. acnes SSI.
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Affiliation(s)
- Marion Caseris
- Pediatric Infectious Disease Department, Robert Debré University Hospital, Paris Diderot University, Paris, France
| | - Brice Ilharreborde
- Pediatric Orthopedic Department, Robert Debré University Hospital, Paris Diderot University, 48 Boulevard sérurier, 75019, Paris, France
| | - Catherine Doit
- Microbiology Department, Robert Debré University Hospital, Paris Diderot University, Paris, France
| | - Anne-Laure Simon
- Pediatric Orthopedic Department, Robert Debré University Hospital, Paris Diderot University, 48 Boulevard sérurier, 75019, Paris, France
| | - Christine Vitoux
- Pediatric Orthopedic Department, Robert Debré University Hospital, Paris Diderot University, 48 Boulevard sérurier, 75019, Paris, France
| | - Nora Poey
- Pediatric Infectious Disease Department, Robert Debré University Hospital, Paris Diderot University, Paris, France
| | - Stéphane Bonacorsi
- Microbiology Department, Robert Debré University Hospital, Paris Diderot University, Paris, France
| | - Cindy Mallet
- Pediatric Orthopedic Department, Robert Debré University Hospital, Paris Diderot University, 48 Boulevard sérurier, 75019, Paris, France.
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Nadig NS, Shaw KA, Parada SA. Exploring Penicillin G as an Intrawound Antibiotic Powder for Prevention of Postoperative Shoulder Infections: Does It Exhibit In Vitro Chondrotoxicity? J Orthop Res 2020; 38:726-730. [PMID: 31724230 DOI: 10.1002/jor.24524] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 10/04/2019] [Indexed: 02/04/2023]
Abstract
Cutibacterium acnes (C. acnes) is a significant insidious pathogen for postoperative infections in shoulder surgery. Studies have demonstrated that certain topical antibiotic powders used have the potential for chondrotoxicity. Benzylpenicillin, commonly referred to as Penicillin G (Pen G) has the lowest minimum inhibitory concentration (MIC) for C. acnes. There is no research regarding the topical application of Pen G during shoulder surgery, nor has its chondrocyte toxicity been previously investigated. This study sought to characterize the in vitro chondrocyte toxicity of Pen G. Culture-derived bovine chondrocytes were exposed to serial Pen G concentrations and compared with a positive and negative control. A negative control of growth medium and positive control of 1% Triton solution. The chondrocyte viability was assessed via spectrophotometer absorbance. The treatment groups were analyzed using one-way repeated measures analysis of variance and Pearson's correlation analysis. The chondrocyte viability was significantly higher for all Pen G concentrations as compared with the positive control (p < 0.001). All concentrations of Pen G exhibited continued chondrocyte metabolic activity over time. Analysis of variance, independent of time, demonstrated no significant decrease in chondrocyte viability for Pen G concentrations ≤6.25 mg/ml, as compared with the negative control (p > 0.05). Pen G demonstrated a significant negative correlation with its concentration and absorbance (r = 0.371, p < 0.001), however, concentrations ≤6.25 mg/ml did not demonstrate a significant decrease in chondrocyte viability (p = 0.063). Pen G in concentrations appropriate for C. acnes is not significantly chondrotoxic and may be safe for intrawound application. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:726-730, 2020.
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Affiliation(s)
- Nischal S Nadig
- Department of Orthopaedic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia
| | - K Aaron Shaw
- Department of Orthopaedic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia
| | - Stephen A Parada
- Department of Orthopaedic Surgery, Medical College of Georgia at Augusta University, Augusta, Georgia
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32
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Singh AM, Sethi PM, Romeo AA, Anakwenze OA, Abboud JA, Namdari S. Strategies to decolonize the shoulder of Cutibacterium acnes: a review of the literature. J Shoulder Elbow Surg 2020; 29:660-666. [PMID: 32197761 DOI: 10.1016/j.jse.2019.11.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 11/27/2019] [Indexed: 02/07/2023]
Abstract
Cutibacterium acnes is the most prevalent cause of joint infection after shoulder surgery. Current methods for decolonizing this bacterium from the shoulder region have proved ineffective owing to its unique niche within dermal sebaceous glands and hair follicles. When we are making decisions to decolonize the skin of C acnes, the risks associated with decolonization must be balanced by the potential benefits of reduced deep tissue inoculation. The purpose of this review was to describe currently available methods of decolonization and their efficacy.
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Affiliation(s)
- Arjun M Singh
- Rothman Institute Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Paul M Sethi
- Orthopaedic & Neurosurgery Specialists, Greenwich, CT, USA
| | - Anthony A Romeo
- Rothman Institute Department of Orthopaedic Surgery, New York, NY, USA
| | - Oke A Anakwenze
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Joseph A Abboud
- Rothman Institute Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Surena Namdari
- Rothman Institute Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
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Couture A, Lavergne V, Sandman E, Leduc JM, Benoit B, Leduc S, Rouleau DM. Calcium sulphate mixed with antibiotics does not decrease efficacy against Cutibacterium acnes (formerly Propionibacterium acnes), in vitro study. J Orthop 2020; 19:138-142. [PMID: 32025121 DOI: 10.1016/j.jor.2019.11.028] [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: 08/21/2019] [Accepted: 11/23/2019] [Indexed: 10/25/2022] Open
Abstract
Background This study explored the in vitro efficacy of antibiotics mixed with calcium sulfate (ACS) against Cutibacterium acnes (C. acnes). Methods C. acnes isolates from orthopaedic infection sites were tested for antimicrobial susceptibility with ACS. Minimal inhibitory concentrations (MIC) were determined with a gradient diffusion method (Etest® strips). Results When tested with Etest®, all 22 isolates were susceptible to penicillin, ceftriaxone, vancomycin, and two were resistant to clindamycin (MICs of 4 and 8 mg/L). Penicillin and rifampin had the largest inhibition zone diameters. Conclusions Antibiotics retained activity against C. acnes when mixed with calcium sulfate.
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Affiliation(s)
- Anne Couture
- Université de Montréal, 2900 Boul., Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada
| | - Valéry Lavergne
- Université de Montréal, 2900 Boul., Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada.,Hôpital Du Sacré-Cœur, Montréal, 5400 Boul. Gouin Ouest, Montreal, QC, H4J 1C5, Canada
| | - Emilie Sandman
- Université de Montréal, 2900 Boul., Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada.,Hôpital Du Sacré-Cœur, Montréal, 5400 Boul. Gouin Ouest, Montreal, QC, H4J 1C5, Canada
| | - Jean-Michel Leduc
- Université de Montréal, 2900 Boul., Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada.,Hôpital Du Sacré-Cœur, Montréal, 5400 Boul. Gouin Ouest, Montreal, QC, H4J 1C5, Canada
| | - Benoit Benoit
- Université de Montréal, 2900 Boul., Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada.,Hôpital Du Sacré-Cœur, Montréal, 5400 Boul. Gouin Ouest, Montreal, QC, H4J 1C5, Canada
| | - Stéphane Leduc
- Université de Montréal, 2900 Boul., Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada.,Hôpital Du Sacré-Cœur, Montréal, 5400 Boul. Gouin Ouest, Montreal, QC, H4J 1C5, Canada
| | - Dominique M Rouleau
- Université de Montréal, 2900 Boul., Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada.,Hôpital Du Sacré-Cœur, Montréal, 5400 Boul. Gouin Ouest, Montreal, QC, H4J 1C5, Canada
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Lin ZX, Steed LL, Marculescu CE, Slone HS, Woolf SK. Cutibacterium acnes Infection in Orthopedics: Microbiology, Clinical Findings, Diagnostic Strategies, and Management. Orthopedics 2020; 43:52-61. [PMID: 31958341 DOI: 10.3928/01477447-20191213-02] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 09/30/2019] [Indexed: 02/03/2023]
Abstract
Cutibacterium (formerly called Propionibacterium) acnes is a human skin flora often implicated in orthopedic infections. The unique characteristics of this microorganism make the diagnosis of infection difficult. The diagnosis often is made based on clinical evidence, radiographic signs, and laboratory and/or surgical findings combined. Treatment often involves both pharmacologic and surgical methods. In addition, formation of biofilms and increased resistance to drugs exhibited by the microorganism can require combined antimicrobial therapy. Prophylactic measures are particularly important, but no single method has been shown to fully eliminate the risk of C acnes infections. Previous reports have focused on C acnes infections involving surgical implants or after certain orthopedic procedures, particularly in the shoulder and spine. This article reviews current clinical, diagnostic, and treatment principles for C acnes in orthopedics in general. [Orthopedics. 2020; 43(1):52-61.].
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Depypere M, Kuehl R, Metsemakers WJ, Senneville E, McNally MA, Obremskey WT, Zimmerli W, Atkins BL, Trampuz A. Recommendations for Systemic Antimicrobial Therapy in Fracture-Related Infection: A Consensus From an International Expert Group. J Orthop Trauma 2020; 34:30-41. [PMID: 31567902 PMCID: PMC6903362 DOI: 10.1097/bot.0000000000001626] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/09/2019] [Indexed: 02/02/2023]
Abstract
Fracture-related infection (FRI) is a major complication in musculoskeletal trauma and one of the leading causes of morbidity. Standardization of general treatment strategies for FRI has been poor. One of the reasons is the heterogeneity in this patient population, including various anatomical locations, multiple fracture patterns, different degrees of soft-tissue injury, and different patient conditions. This variability makes treatment complex and hard to standardize. As these infections are biofilm-related, surgery remains the cornerstone of treatment, and this entails multiple key aspects (eg, fracture fixation, tissue sampling, debridement, and soft-tissue management). Another important aspect, which is sometimes less familiar to the orthopaedic trauma surgeon, is systemic antimicrobial therapy. The aim of this article is to summarize the available evidence and provide recommendations for systemic antimicrobial therapy with respect to FRI, based on the most recent literature combined with expert opinion. LEVEL OF EVIDENCE:: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Melissa Depypere
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Richard Kuehl
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Basel, Basel, Switzerland
| | | | - Eric Senneville
- Department of Infectious Diseases, Gustave Dron Hospital, University of Lille, Lille, France
| | - Martin A. McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - William T. Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN
| | - Werner Zimmerli
- Kantonsspital Baselland, Interdisciplinary Unit for Orthopedic Infections, Liestal, Switzerland; and
| | - Bridget L. Atkins
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Andrej Trampuz
- Center for Musculoskeletal Surgery, Charité—Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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36
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Arain AR, Cole K, Moral M, Thadani S, Rosenbaum A. Bilateral native knee septic arthritis due to Propionibacterium acnes; a case report and review of literature. Clin Case Rep 2019; 7:1605-1607. [PMID: 31428401 PMCID: PMC6692996 DOI: 10.1002/ccr3.2298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 06/08/2019] [Accepted: 06/16/2019] [Indexed: 12/13/2022] Open
Abstract
Propionibacterium acnes should be considered in any case of indolent septic arthritis. Cultures should be followed for 2 weeks as our cultures were negative for 7 days before growing P. acnes. Irrigation and debridement followed by antibiotics is the standard of care.
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Arain AR, Sullivan CW, Angelicola‐Richardson K, Haddad S, Rosenbaum A. Indolent Propionibacterium acnes infection associated with orthopedic hardware in the ankle: A case report and literature review. Clin Case Rep 2019; 7:1494-1498. [PMID: 31428375 PMCID: PMC6692978 DOI: 10.1002/ccr3.2283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 06/06/2019] [Indexed: 11/22/2022] Open
Abstract
Propionibacterium acnes (P. acnes) infections of the foot and ankle are very rare and require a unique approach to prevention, diagnosis, and treatment. Clinicians should consider P. acnes as a cause for all late and indolent orthopedic infections, as appropriate surgical and medical management can result in a good outcome.
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Nodzo SR, Boyle KK, Frisch NB. Nationwide Organism Susceptibility Patterns to Common Preoperative Prophylactic Antibiotics: What Are We Covering? J Arthroplasty 2019; 34:S302-S306. [PMID: 30745218 DOI: 10.1016/j.arth.2019.01.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 01/05/2019] [Accepted: 01/09/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Many periprosthetic joint infections (PJIs) are caused by organisms not susceptible to first-generation cephalosporins. We sought to evaluate the national susceptibility patterns of organisms to cefazolin and, or oxacillin, clindamycin, and vancomycin using antibiogram data. METHODS Publically available regional and state antibiograms were evaluated for antibiotic susceptibility patterns to commonly infecting gram-positive organisms. The number of isolates tested in each antibiogram and percent of strains susceptible to oxacillin, clindamycin, and vancomycin were recorded. Oxacillin is used as a surrogate to cefazolin in antibiograms. A comparison of antibiotic susceptibilities was performed. RESULTS Seven state and 38 regional antibiograms were reviewed. Oxacillin was a sensitive antibiotic in 99.2 ± 4.8% of methicillin-sensitive Staphylococcus aureus (MSSA) isolates, 0 ± 0% of methicillin-resistant Staphylococcus aureus (MRSA) isolates, 44.5 ± 13.7% of coagulase-negative staphylococcus organism isolates (CNS), and 30.6 ± 10.5% of Staphylococcus epidermidis isolates. Clindamycin was a sensitive antibiotic in 75.8 ± 8.4% of MSSA isolates, 60.2 ± 13.2% of MRSA isolates, 60.3 ± 11.4% of CNS isolates, and 56.2 ± 6.5% of S epidermidis isolates. Vancomycin was a sensitive antibiotic in 99.9 ± 0.4% of MSSA isolates, 99.8 ± 0.4% of MRSA isolates, 99.8 ± 0.5% of CNS isolates, and 99.6 ± 0.7% of S epidermidis isolates. Clindamycin was significantly less sensitive in MSSA isolates as compared with oxacillin and vancomycin (P < .0001). Oxacillin was significantly less sensitive in CNS, S epidermidis, and MRSA isolates as compared with clindamycin and vancomycin (P < .0001). CONCLUSION The national clindamycin susceptibility pattern is limited to MSSA and may not have an optimal susceptibility profile suitable for use as a prophylactic antibiotic. Cefazolin continues to have excellent coverage against MSSA.
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Affiliation(s)
- Scott R Nodzo
- Mike O'Callaghan Medical Center, Department of Orthopedics, Las Vegas, NV
| | - K Keely Boyle
- Department of Orthopedics, University at Buffalo, Buffalo, NY
| | - Nicholas B Frisch
- Ascencion Crittenton Hospital, Department of Orthopedics, Rochester, MI
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Egglestone A, Ingoe H, Rees J, Thomas M, Jeavons R, Rangan A. Scoping review: Diagnosis and management of periprosthetic joint infection in shoulder arthroplasty. Shoulder Elbow 2019; 11:167-181. [PMID: 31210788 PMCID: PMC6555110 DOI: 10.1177/1758573218779076] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 04/30/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND The aim of this scoping review is to assess the current evidence regarding periprosthetic shoulder infection to inform development of evidence and consensus-based guidelines. METHODS A search of Medline, Embase and PubMed was performed; two authors screened the results independently for inclusion. RESULTS Totally 88 studies were included. Incidence of periprosthetic shoulder infection ranged from 0.7% to 7%. The most common organisms to cause periprosthetic shoulder infection were Propionibacterium acnes, Staphylococcus aureus, Staphylococcus epidermidis and coagulase-negative Staphylococcus. Male gender and younger age are the most reported risk factors. Erythrocyte sedimentation rate, C-reactive protein and serum/synovial biomarkers had limited diagnostic accuracy. Thirty-nine studies reported the outcome of surgical management of periprosthetic shoulder infection. Eradication rates vary from 54% to 100% for debridement procedures; 66-100% for permanent spacers; 50-100% following single-stage revision; 60-100% following two-stage revision; and 66-100% following resection arthroplasty. CONCLUSION There is wide heterogeneity in study designs and outcomes of studies are often contradictory and due to issues with methodology and small sample sizes the optimal pathways for diagnosis and management cannot be determined from this review. Future research should be based on larger cohorts and randomised trials where feasible to provide more valid research for guiding future treatment of periprosthetic shoulder infection.
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Affiliation(s)
- Anthony Egglestone
- Trauma and Orthopaedic Department, James Cook University Hospital, Middlesbrough, UK
| | - Helen Ingoe
- Trauma and Orthopaedic Department, James Cook University Hospital, Middlesbrough, UK
| | - Jonathan Rees
- Nuffield Department of Orthopaedic Surgery, Nuffield Orthopaedic Centre, Oxford, UK
| | - Michael Thomas
- Heatherwood and Wexham Park Hospitals Trust, Berkshire, UK
| | - Richard Jeavons
- North Tees and Hartlepool NHS Foundation Trust, Stockton on Tees, UK
| | - Amar Rangan
- Trauma and Orthopaedic Department, James Cook University Hospital, Middlesbrough, UK
- Faculty of Medical Sciences & NDORMS, University of Oxford, Oxford, UK
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Garrigues GE, Zmistowski B, Cooper AM, Green A. Proceedings from the 2018 International Consensus Meeting on Orthopedic Infections: management of periprosthetic shoulder infection. J Shoulder Elbow Surg 2019; 28:S67-S99. [PMID: 31196516 DOI: 10.1016/j.jse.2019.04.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 04/20/2019] [Indexed: 02/05/2023]
Abstract
The Second International Consensus Meeting on Orthopedic Infections was held in Philadelphia, Pennsylvania, in July 2018. A multidisciplinary team of international experts from all 9 subspecialties of orthopedic surgery and allied fields of infectious disease, microbiology, and epidemiology was assembled to form the International Consensus Group. The following consensus proceedings from the International Consensus Meeting involve 30 questions pertaining to the management of periprosthetic shoulder infection.
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Affiliation(s)
- Grant E Garrigues
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA.
| | - Benjamin Zmistowski
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexus M Cooper
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Andrew Green
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI, USA
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Ridberg S, Hellmark B, Nilsdotter Å, Söderquist B. Cutibacterium acnes (formerly Propionibacterium acnes) isolated from prosthetic joint infections is less susceptible to oxacillin than to benzylpenicillin. J Bone Jt Infect 2019; 4:106-110. [PMID: 31192108 PMCID: PMC6536807 DOI: 10.7150/jbji.30954] [Citation(s) in RCA: 5] [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: 10/25/2018] [Accepted: 03/12/2019] [Indexed: 01/22/2023] Open
Abstract
Introduction: The frequency of prosthetic joint infections (PJIs) due to Cutibacterium acnes (formerly Propionibacterium acnes) is increasing, especially shoulder PJIs. The recommended antibiotic prophylaxis for hip and knee arthroplasties is beta-lactam antibiotics, predominantly cephalosporins. However, for example in Sweden, isoxazolyl-penicillin cloxacillin is used. No specific recommendations for shoulder arthroplasties are available. The aim of the present study was to determine the minimum inhibitory concentration (MIC) values for different antibiotics for C. acnes; and, more specifically, to compare the MIC values for benzylpenicillin and oxacillin. Materials and methods: Minimum inhibitory concentration (MIC) values for nine different antibiotic agents were obtained by gradient test (Etest) using strains of C. acnes (n= 57) isolated from PJIs from shoulders (n=31), hips (n=21), and knees (n=5). Results: All isolates had low MIC values for most of the tested antibiotic agents, and showed a wild type MIC distribution. The exception was clindamycin with 9% of the isolates displaying decreased susceptibility. The MIC values obtained for benzylpenicillin were significantly lower than the MIC values for isoxazolyl-penicillin (oxacillin). Conclusion: These in vitro results indicate that benzylpenicillin might be a more effective prophylactic treatment to prevent shoulder PJIs caused by C. acnes. However, further studies on the subject are needed, and the effectiveness of the prophylactic treatment should be evaluated using randomized controlled studies and/or register-based studies.
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Affiliation(s)
- Sara Ridberg
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Bengt Hellmark
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Åsa Nilsdotter
- Department of Infectious Diseases and Department of Clinical and Experimental Medicine, Linköping University, Norrköping, Sweden
| | - Bo Söderquist
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Hemolysis Is a Diagnostic Adjuvant for Propionibacterium acnes Orthopaedic Shoulder Infections. J Am Acad Orthop Surg 2019; 27:136-144. [PMID: 30247311 DOI: 10.5435/jaaos-d-17-00394] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION The purpose of this study was to further evaluate the pathogenicity of hemolytic and nonhemolytic phenotypes of Propionibacterium acnes (P acnes) isolates from shoulders of orthopaedic patients. METHODS Thirty-one patient records were reviewed, which had a positive P acnes shoulder culture from joint aspiration fluid and/or intraoperative tissues for demographics, clinical course, culture, and laboratory data. Patients were categorized as definite infection, probable infection, or probable contaminant. Antibiotic resistance patterns and hemolysis characteristics were subsequently analyzed. RESULTS Hemolysis demonstrated 100% specificity with a positive predictive value of 100% and 80% sensitivity with a negative predictive value of 73% for determining definite and probable infections. Hundred percent of the patients in the hemolytic group and only 27% of patients in the nonhemolytic group were classified as infected. Presenting inflammatory markers were markedly higher in the hemolytic group. Clindamycin resistance was found in 31% of the hemolytic strains, whereas no antibiotic resistance was observed in the nonhemolytic group. CONCLUSION Hemolytic strains of P acnes exhibit enhanced pathogenicity to their host by eliciting a more prominent systemic inflammatory response, increased antibiotic resistance, and a more challenging clinical course. Hemolysis may serve as a specific marker for assisting in diagnosing true infection with P acnes. LEVEL OF EVIDENCE Level III retrospective comparative study.
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Abstract
Objectives The purpose of this study was to examine the bactericidal efficacy of hydrogen peroxide (H2O2) on Cutibacterium acnes (C. acnes). We hypothesize that H2O2 reduces the bacterial burden of C. acnes. Methods The effect of H2O2 was assessed by testing bactericidal effect, time course analysis, growth inhibition, and minimum bactericidal concentration. To assess the bactericidal effect, bacteria were treated for 30 minutes with 0%, 1%, 3%, 4%, 6%, 8%, or 10% H2O2 in saline or water and compared with 3% topical H2O2 solution. For time course analysis, bacteria were treated with water or saline (controls), 3% H2O2 in water, 3% H2O2 in saline, or 3% topical solution for 5, 10, 15, 20, and 30 minutes. Results were analyzed with a two-way analysis of variance (ANOVA) (p < 0.05). Results Minimum inhibitory concentration of H2O2 after 30 minutes is 1% for H2O2 prepared in saline and water. The 3% topical solution was as effective when compared with the 1% H2O2 prepared in saline or water. The controls of both saline and water showed no reduction of bacteria. After five minutes of exposure, all mixtures of H2O2 reduced the percentage of live bacteria, with the topical solution being most effective (p < 0.0001). Maximum growth inhibition was achieved with topical 3% H2O2. Conclusion The inexpensive and commercially available topical solution of 3% H2O2 demonstrated superior bactericidal effect as observed in the minimum bactericidal inhibitory concentration, time course, and colony-forming unit (CFU) inhibition assays. These results support the use of topical 3% H2O2 for five minutes before surgical skin preparation prior to shoulder surgery to achieve eradication of C. acnes for the skin.Cite this article: P. Hernandez, B. Sager, A. Fa, T. Liang, C. Lozano, M. Khazzam. Bactericidal efficacy of hydrogen peroxide on Cutibacterium acnes. Bone Joint Res 2019;8:3-10. DOI: 10.1302/2046-3758.81.BJR-2018-0145.R1.
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Affiliation(s)
- P Hernandez
- Institute for Research in Dental Sciences, Faculty of Dentistry, University of Chile, Santiago, Chile
| | - B Sager
- Institute for Research in Dental Sciences, Faculty of Dentistry, University of Chile, Santiago, Chile
| | - A Fa
- Institute for Research in Dental Sciences, Faculty of Dentistry, University of Chile, Santiago, Chile
| | - T Liang
- Department of Orthopaedic Surgery; Shoulder Service, University of Texas Southwestern Medical Center, Texas, USA
| | - C Lozano
- Institute for Research in Dental Sciences, Faculty of Dentistry, University of Chile, Santiago, Chile
| | - M Khazzam
- Department of Orthopaedic Surgery; Shoulder Service, University of Texas Southwestern Medical Center, Texas, USA
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Boyle KK, Kuo FC, Horcajada JP, Hughes H, Cavagnaro L, Marculescu C, McLaren A, Nodzo SR, Riccio G, Sendi P, Silibovsky R, Stammers J, Tan TL, Wimmer M. General Assembly, Treatment, Antimicrobials: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S225-S237. [PMID: 30360976 DOI: 10.1016/j.arth.2018.09.074] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Zimmermann P, Curtis N. The role of Cutibacterium acnes in auto-inflammatory bone disorders. Eur J Pediatr 2019; 178:89-95. [PMID: 30324232 DOI: 10.1007/s00431-018-3263-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 09/10/2018] [Accepted: 09/24/2018] [Indexed: 12/15/2022]
Abstract
Chronic nonbacterial osteomyelitis (CNO) and SAPHO (synovitis, acne, pustulosis, hyperostosis and osteitis) syndrome are auto-inflammatory disorders manifesting as chronic inflammation of bones and joints, which in SAPHO is often accompanying by skin changes. The aetiology of these diseases is unknown, but includes genetic, infectious and immunological components. It has been proposed that Cutibacterium (formerly Propionibacterium) acnes plays a role in the pathogenesis. In this review, we summarise reported cases of CNO or SAPHO syndrome in which C. acnes has been isolated from bones. To identify cases, a search was done in May 2018 using the MEDLINE Ovid interface (1946 to present). We found 14 publications reporting 98 patients with auto-inflammatory bone disorders, of whom 48 (49%) had positive bone biopsies for C. acnes. This bacterium was more frequently isolated from open biopsies than percutaneous ones (43/69 (62%) vs 1/7 (14%); p = 0.04) and biopsies were more frequently positive in patients who presented with simultaneous skin manifestations (19/36 (53%) vs 4/12 (33%); p = 0.03).Conclusion: In patients with CNO or SAPHO, C. acnes can be isolated from open biopsies suggesting that in these patients, C. acnes might be a pathogen rather than a contaminant. The fact that biopsies are more frequently positive in patients who present with simultaneous skin manifestations suggests that these individuals might have a genetic predisposition for impaired clearance of C. acnes. What is known • Chronic nonbacterial osteomyelitis (CNO) and SAPHO (synovitis, acne, pustulosis, hyperostosis and osteitis) syndrome are auto-inflammatory disorders manifesting as inflammation of bones. Both diseases are an important differential diagnosis in children who present with symptoms of (multifocal) osteomyelitis. • The pathogenesis of CNO and SAPHO is multifactorial emcompassing genetic, infectious and immunological components, including interleukin (IL)-1 dysregulation. There is a controversy as to whether Cutibacterium (formerly Propionibacterium) acnes plays a role in the aetiology of CNO and SAPHO. It has been postulated that the presence of C. acnes might trigger auto-inflammatory chronic inflammation in genetically predisposed individuals. What is new • In patients with CNO or SAPHO, C. acnes can be isolated more frequently from open biopsies, than from percutaneous ones, suggesting that C. acnes might be a pathogen rather than a contaminant. • Biopsies are more frequently positive in patients who present with simultaneous skin manifestations suggesting that these individuals might have a genetic predisposition for impaired clearance of C. acnes. Impaired C. acnes clearance likely leads to increased IL-1 beta (β) production by skin cells, bone cells and phagocytes, which is one of the main cytokines underlying chronic inflammatory bone disorders.
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Affiliation(s)
- Petra Zimmermann
- Department of Paediatrics, The University of Melbourne, Parkville, Australia. .,Infectious Diseases Unit, The Royal Children's Hospital Melbourne, Parkville, 3052, Australia. .,Infectious Diseases & Microbiology Research Group, Murdoch Children's Research Institute, Parkville, Australia. .,Infectious Diseases Unit, University of Basel Children's Hospital, Basel, Switzerland.
| | - Nigel Curtis
- Department of Paediatrics, The University of Melbourne, Parkville, Australia. .,Infectious Diseases Unit, The Royal Children's Hospital Melbourne, Parkville, 3052, Australia. .,Infectious Diseases & Microbiology Research Group, Murdoch Children's Research Institute, Parkville, Australia.
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Skedros JG, Henrie MK, Finlinson ED, Trachtenberg JD. Polymicrobial anaerobic infection with a deep abscess in the supraspinous fossa following a subacromial corticosteroid injection. BMJ Case Rep 2018; 11:11/1/e226598. [PMID: 30567107 PMCID: PMC6301599 DOI: 10.1136/bcr-2018-226598] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
In September 2015, a male aged 61 years with poorly controlled diabetes (his only medical problem) had left shoulder surgery that included an arthroscopic acromioplasty with debridement of suture material from a rotator cuff repair done 10 years prior. A subacromial corticosteroid injection was given 7 months later for pain and reduced motion. Three weeks later a fulminate infection was evident. Cultures grew Propionibacterium acnes. Treatment included two arthroscopic debridement surgeries and 8 weeks of intravenous antibiotics (primarily daptomycin). Eight weeks after the cessation of the antibiotics, purulence recurred and tissue cultures then grew Staphylococcus epidermidis. Several additional surgeries were needed to control the infection. We failed to recognise that an abscess that extended from the subacromial space across the entire supraspinous fossa. We report this case to alert clinicians that a seemingly innocuous subacromial corticosteroid injection can lead to an atypical infection and also extend into the supraspinous fossa.
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Abstract
PURPOSE OF REVIEW Organism identification and antibiotic selection remain a critical component of periprosthetic joint infection (PJI) treatment. Prior to organism identification and/or the availability of antibiotic sensitivities, empiric antibiotics are routinely started. A basic understanding of a region or institutions antibiogram is paramount for selection of an empiric treatment regimen. Evolving antibiogram results and regional antibiotic resistance are important to follow as this may change antibiotic selection in some patient populations. RECENT FINDINGS The Clinical Laboratory and Standards Institute (CLSI) has created guidelines and standards for the creation and maintenance of antibiograms that should be followed by institutions. The infecting organism during PJI may be different in acute vs chronic infections and empiric therapy may change depending on the timing. Antibiotic prophylaxis for major procedures in certain patient populations should be critically evaluated based on regional and national antibiogram results. The CLSI guides recommendations and antibiotic resistance testing techniques and should be consulted when creating an antibiogram. The local and regional antibiogram should be consulted prior to administration of empiric and prophylactic antibiotics.
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48
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Clark JJC, Abildgaard JT, Backes J, Hawkins RJ. Preventing infection in shoulder surgery. J Shoulder Elbow Surg 2018; 27:1333-1341. [PMID: 29444755 DOI: 10.1016/j.jse.2017.12.028] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 12/06/2017] [Accepted: 12/12/2017] [Indexed: 02/01/2023]
Abstract
Although rare, infection after shoulder surgery can represent a devastating complication. Infection can negatively affect clinical outcomes, and eradication often requires a protracted treatment course. Staphylococcus aureus, Staphylococcus epidermidis, and Cutibacterium acnes are among the most frequently isolated pathogens. Perioperative measures can be implemented to reduce infection risk. Here we review various perioperative practices and their efficacy at reducing infection after shoulder surgery.
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49
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Rao AJ, Chalmers PN, Cvetanovich GL, O'Brien MC, Newgren JM, Cole BJ, Verma NN, Nicholson GP, Romeo AA. Preoperative Doxycycline Does Not Reduce Propionibacterium acnes in Shoulder Arthroplasty. J Bone Joint Surg Am 2018; 100:958-964. [PMID: 29870447 DOI: 10.2106/jbjs.17.00584] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Propionibacterium acnes (P. acnes) is the most common bacteria associated with infection after shoulder arthroplasty. These bacteria can be grown on culture of skin after standard preoperative skin preparation and antibiotics. The purpose of this study was to determine whether adding preoperative intravenous doxycycline reduces the prevalence of positive P. acnes cultures of skin and deep tissues at the time of prosthetic joint implantation during shoulder arthroplasty. METHODS This was a randomized controlled trial. An a priori power analysis determined that a sample size of 56 patients was necessary. Patients scheduled to undergo shoulder arthroplasty were randomized to receive either standard perioperative cefazolin or a combination of doxycycline and cefazolin. Tissue specimens for culture were then taken from the skin edge, and swabs of the superficial dermal tissue and glenohumeral joint were obtained. All cultures were maintained for 14 days to allow for P. acnes detection. Groups were compared to determine if the addition of doxycycline reduced the rate of culture positivity. RESULTS Fifty-six patients were enrolled and randomized. Twenty-one (38%) had ≥1 positive cultures for P. acnes, with no significant difference between the group treated with cefazolin alone (10 [37%] of 27 patients) and the combined doxycycline and cefazolin group (11 [38%] of 29 patients) (p = 0.99). The greatest numbers of culture-positive samples were obtained from the skin (30%), followed by dermal tissue (20%) and the glenohumeral joint (5%). Patients who had ≥1 positive cultures were younger than those who did not (mean age [and standard deviation], 64.9 ± 7.7 versus 69.4 ± 7.7 years; p = 0.041), had a greater tendency to be male (16 [76%] of 21 versus 17 [49%] of 35; p = 0.053), and had a lower Charlson Comorbidity Index (3.35 ± 1.3 versus 4.09 ± 1.4; p = 0.051). There were no significant differences between the culture-positive and culture-negative groups in terms of body mass index (BMI) (p = 0.446) or arthroplasty type, with positive cultures found for 8 of the 29 anatomic shoulder arthroplasty procedures compared with 13 of the 27 reverse shoulder arthroplasty procedures (p = 0.280). There were no doxycycline-related adverse events. CONCLUSIONS In this randomized controlled trial, doxycycline did not significantly decrease P. acnes culture positivity of the skin, dermis, or glenohumeral joint of patients undergoing shoulder arthroplasty. The addition of prophylactic intravenous antibiotics to cover P. acnes may not be an effective method to reduce postoperative and periprosthetic shoulder joint infections. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Allison J Rao
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Peter N Chalmers
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois.,Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Gregory L Cvetanovich
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Michael C O'Brien
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Jon M Newgren
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Brian J Cole
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Nikhil N Verma
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Gregory P Nicholson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Anthony A Romeo
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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50
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Boyle KK, Duquin TR. Antibiotic Prophylaxis and Prevention of Surgical Site Infection in Shoulder and Elbow Surgery. Orthop Clin North Am 2018; 49:241-256. [PMID: 29499825 DOI: 10.1016/j.ocl.2017.11.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Infection after orthopedic procedures is a devastating and serious complication associated with significant clinical and financial challenges to the health care system and unfortunate patient. The time and resource-intensive nature of treating infection after orthopedic procedures has turned attention toward enhancing prevention and establishing quality improvement measures. Prevention strategies throughout the perioperative period include host optimization, risk mitigation, reducing bacterial burden and proper wound management. Understanding the most common offending organisms of the shoulder, Propionibacterium acnes and coagulase negative Staphylococcus species, and their hypothesized mechanism of infection is crucial to selecting appropriate preventative measures.
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Affiliation(s)
- K Keely Boyle
- Department of Orthopaedics, State University of New York at Buffalo, Erie County Medical Center, 462 Grider Street, Buffalo, NY 14215, USA.
| | - Thomas R Duquin
- Department of Orthopaedics, State University of New York at Buffalo, Erie County Medical Center, 462 Grider Street, Buffalo, NY 14215, USA
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