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Crutcher WL, Acidera JC, Whitson AJ, Matsen FA, Hsu JE. Does adding hydrogen peroxide to chlorhexidine gluconate increase the effectiveness of skin preparation in reducing cutaneous Cutibacterium levels? A randomized controlled trial. J Shoulder Elbow Surg 2024; 33:1905-1908. [PMID: 38815731 DOI: 10.1016/j.jse.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 03/27/2024] [Accepted: 04/08/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Shoulder periprosthetic joint infection is most commonly caused by Cutibacterium. Effective removal of these bacteria from the skin is difficult because Cutibacterium live protected in the dermal sebaceous glands beneath the skin surface to which surgical preparation solutions, such as chlorhexidine gluconate (CHG), are applied. There is conflicting evidence on the additional benefit of using hydrogen peroxide (H2O2) as an adjunct to CHG in eliminating Cutibacterium from the skin. A previous study demonstrated that after CHG skin preparation, repopulation of Cutibacterium from sebaceous glands onto the skin surface occurs in 90% of shoulders by 60 minutes after application. The objective of this randomized controlled study was to determine the effectiveness of adding H2O2 to CHG in reducing skin Cutibacterium. METHODS Eighteen male volunteers (36 shoulders) were recruited for this study. The 2 shoulders of each volunteer were randomized to receive the control preparation ("CHG-only" - 2% CHG in 70% isopropyl alcohol alone) or the study preparation ("H2O2+CHG" - 3% H2O2 followed by 2% CHG in 70% isopropyl alcohol). Skin swabs were taken from each shoulder prior to skin preparation and again at 60 minutes after preparation. Swabs were cultured for Cutibacterium and observed for 14 days. Cutibacterium skin load was reported using a semiquantitative system based on the number of quadrants growing on the culture plate. RESULTS Prior to skin preparation, 100% of the CHG-only shoulders and 100% of the H2O2+CHG shoulders had positive skin surface cultures for Cutibacterium. Repopulation of Cutibacterium on the skin at 60 minutes occurred in 78% of CHG-only and 78% of H2O2+CHG shoulders (P = 1.00). Reduction of Cutibacterium skin levels occurred in 56% of CHG-only and 61% of H2O2+CHG shoulders (P = .735). Cutibacterium levels were significantly decreased from before skin preparation to 60 minutes after preparation in both the CHG-only (2.1 ± 0.8 to 1.3 ± 0.9, P = .003) and the H2O2+CHG groups (2.2 ± 0.7 to 1.4 ± 0.9, P < .001). Substantial skin surface levels of Cutibacterium were present at 60 minutes after both preparations. CONCLUSIONS In this randomized controlled study, there was no additional benefit of using hydrogen peroxide as an adjunct to chlorhexidine gluconate skin preparation in the reduction of cutaneous Cutibacterium levels. Neither preparation was able to eliminate repopulation of Cutibacterium on the skin surface from the dermal sebaceous glands.
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Affiliation(s)
- William L Crutcher
- Department of Orthopedics and Sports Medicine, Investigation Performed at the University of Washington, Seattle, WA, USA
| | - Joshua C Acidera
- Department of Orthopedics and Sports Medicine, Investigation Performed at the University of Washington, Seattle, WA, USA
| | - Anastasia J Whitson
- Department of Orthopedics and Sports Medicine, Investigation Performed at the University of Washington, Seattle, WA, USA
| | - Frederick A Matsen
- Department of Orthopedics and Sports Medicine, Investigation Performed at the University of Washington, Seattle, WA, USA
| | - Jason E Hsu
- Department of Orthopedics and Sports Medicine, Investigation Performed at the University of Washington, Seattle, WA, USA.
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Baez C, MacDonell R, Tishad A, Prieto HA, Miley EN, Deen JT, Gray CF, Parvataneni HK, Pulido L. Comparison of Five-Day vs. Fourteen-Day Incubation of Cultures for Diagnosis of Periprosthetic Joint Infection in Hip Arthroplasty. J Clin Med 2024; 13:4467. [PMID: 39124734 PMCID: PMC11313486 DOI: 10.3390/jcm13154467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2024] [Revised: 07/15/2024] [Accepted: 07/17/2024] [Indexed: 08/12/2024] Open
Abstract
Background: Periprosthetic joint infections (PJI) are among the most morbid complications in total hip arthroplasty (THA). The ideal incubation time, however, for intraoperative cultures for PJI diagnosis remains unclear. As such, the aim of this study was to determine if any differences existed in culture-positive rates and organism detection between five-day and fourteen-day cultures. Methods: This retrospective cohort study consisted of THA cases diagnosed with PJI performed between May 2014 and May 2020 at a single tertiary-care institution. Analyses compared five-day and fourteen-day cultures and carried out a pre-specified subgroup analysis by organism and PJI type. Results: A total of 147 surgeries were performed in 101 patients (57.1% females), of which 65% (n = 98) obtained five-day cultures and 34% (n = 49) obtained fourteen-day cultures. The positive culture rate was 67.3% (n = 99) with Staphylococcus aureus being the most common pathogen identified (n = 41 specimens, 41.4%). The positive culture rate was not significantly different between groups (66.3% five-day, 69.4% fourteen-day, p = 0.852). Fourteen-day cultures had a significantly longer time-to-positive culture (5.0 days) than five-day cultures (3.0 days, p < 0.001), a higher rate of fungi (5.6% vs. 0%), and a lower rate of Gram-negatives (4.5% vs. 18.7%, p = 0.016). Conclusions: Fourteen-day cultures did not increase the positivity rate, had higher rates of slow-growth pathogens, and had a longer time-to-positivization than five-day cultures. Prolonged culture holds may provide more thorough organism detection for PJI without increasing the diagnostic culture yield.
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Affiliation(s)
- Catalina Baez
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL 32607, USA; (R.M.); (H.A.P.); (E.N.M.)
| | - Robert MacDonell
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL 32607, USA; (R.M.); (H.A.P.); (E.N.M.)
| | - Abtahi Tishad
- College of Medicine, University of Florida, Gainesville, FL 32607, USA;
| | - Hernan A. Prieto
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL 32607, USA; (R.M.); (H.A.P.); (E.N.M.)
| | - Emilie N. Miley
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL 32607, USA; (R.M.); (H.A.P.); (E.N.M.)
| | - Justin T. Deen
- Florida Orthopaedic Institute, Gainesville, FL 32607, USA; (J.T.D.); (C.F.G.); (H.K.P.)
| | - Chancellor F. Gray
- Florida Orthopaedic Institute, Gainesville, FL 32607, USA; (J.T.D.); (C.F.G.); (H.K.P.)
| | - Hari K. Parvataneni
- Florida Orthopaedic Institute, Gainesville, FL 32607, USA; (J.T.D.); (C.F.G.); (H.K.P.)
| | - Luis Pulido
- Florida Orthopaedic Institute, Gainesville, FL 32607, USA; (J.T.D.); (C.F.G.); (H.K.P.)
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Hewlett AL, Cortés-Penfield N, Ohnoutka CJ, Tande AJ. What Orthopaedic Infectious Diseases Specialists Want. J Bone Joint Surg Am 2024:00004623-990000000-01129. [PMID: 38875347 DOI: 10.2106/jbjs.24.00166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/16/2024]
Affiliation(s)
- Angela L Hewlett
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, Nebraska
- Orthopedic Infectious Diseases Service, University of Nebraska Medical Center, Omaha, Nebraska
| | - Nicolás Cortés-Penfield
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska
- Orthopedic Infectious Diseases Service, University of Nebraska Medical Center, Omaha, Nebraska
| | - Cole J Ohnoutka
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, Nebraska
| | - Aaron J Tande
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
- Orthopedic Infectious Diseases Focus Group, Mayo Clinic College of Medicine, Rochester, Minnesota
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Wang Q, Chen Y, Chen Y, Lv J, Ding H, Huang J, Huang J, Huang Z, Yang B, Zhang W, Fang X. Improved cure rate of periprosthetic joint infection through targeted antibiotic therapy based on integrated pathogen diagnosis strategy. Front Cell Infect Microbiol 2024; 14:1388385. [PMID: 38836059 PMCID: PMC11148460 DOI: 10.3389/fcimb.2024.1388385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 04/18/2024] [Indexed: 06/06/2024] Open
Abstract
Objectives This study aimed to determine whether combined of pathogen detection strategies, including specimen acquisition, culture conditions, and molecular diagnostics, can improve treatment outcomes in patients with periprosthetic joint infections (PJI). Methods This retrospective study included suspected PJI cases from three sequential stages at our institution: Stage A (July 2012 to June 2015), Stage B (July 2015 to June 2018), and Stage C (July 2018 to June 2021). Cases were categorized into PJI and aseptic failure (AF) groups based on European Bone and Joint Infection Society (EBJIS) criteria. Utilization of pathogen diagnostic strategies, pathogen detection rates, targeted antibiotic prescription rates, and treatment outcomes were analyzed and compared across the three stages. Results A total of 165 PJI cases and 38 AF cases were included in this study. With the progressive implementation of the three optimization approaches across stages A, B and C, pathogen detection rates exhibited a gradual increase (χ2 = 8.282, P=0.016). Similarly, utilization of targeted antibiotic therapy increased stepwise from 57.1% in Stage A, to 82.3% in Stage B, and to 84% in Stage C (χ2 = 9.515, P=0.009). The 2-year infection control rate exceeded 90% in both stages B and C, surpassing stage A (71.4%) (χ2 = 8.317, P=0.011). Combined application of all three optimized protocols yielded the highest sensitivity of 91.21% for pathogen detection, while retaining higher specificity of 92.11%. Conclusion The utilization of combined pathogen diagnostic strategies in PJI can increase pathogen detection rates, improve targeted antibiotic prescription, reduce the occurrence of antibiotic complications, and achieve better treatment outcomes.
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Affiliation(s)
- Qijin Wang
- Department of Orthopaedic Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Orthopedics, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Orthopaedic Surgery, The Affiliated Mindong Hospital of Fujian Medical University, Fuan, China
| | - Yongfa Chen
- Department of Orthopaedic Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Orthopedics, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Yang Chen
- Department of Orthopaedic Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Orthopedics, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Jianhua Lv
- Department of Orthopaedic Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Orthopedics, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Haiqi Ding
- Department of Orthopaedic Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Orthopedics, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Jiagu Huang
- Department of Orthopaedic Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Orthopedics, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Jiexin Huang
- Department of Orthopaedic Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Orthopedics, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Zida Huang
- Department of Orthopaedic Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Orthopedics, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Bin Yang
- Department of Laboratory Medicine, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Wenming Zhang
- Department of Orthopaedic Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Orthopedics, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Xinyu Fang
- Department of Orthopaedic Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Orthopedics, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
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Tsai SW, Mu W, Parvizi J. Culture-negative periprosthetic joint infections: Do we have an issue? J Clin Orthop Trauma 2024; 52:102430. [PMID: 38783996 PMCID: PMC11108966 DOI: 10.1016/j.jcot.2024.102430] [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: 03/14/2024] [Revised: 05/02/2024] [Accepted: 05/08/2024] [Indexed: 05/25/2024] Open
Abstract
Culture-negative periprosthetic joint infection (PJI) poses a significant challenge in clinical settings. The lack of information on causative organism(s) leads to uncertainties regarding the choice of antimicrobial treatment, which can potentially adversely influence the outcome. Recent advances in molecular-based diagnostic methods have the potential to address the difficulties associated with culture-negative PJIs. These technologies offer a solution to the existing clinical dilemma by providing identification of pathogens and guiding appropriate antimicrobial treatment. In this narrative review, we provide information regarding: 1) incidence and risk factors for culture-negative PJI; 2) the optimal antimicrobial therapy and duration of treatment for culture-negative PJI; 3) outcome comparison between culture-positive and culture-negative PJI; and 4) utilization of novel molecular diagnostic methods in culture-negative PJI, including pathogen identification, and the implementation of an antibiotic stewardship program.
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Affiliation(s)
- Shang-Wen Tsai
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Wenbo Mu
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Javad Parvizi
- International Joint Center, Acibadem University, Istanbul, Turkey
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Hsu JE, Matsen FA, Whitson AJ, Waalkes A, Almazan J, Bourassa LA, Salipante SJ, Long DR. 2023 Neer Award for Basic Science: Genetics of Cutibacterium acnes in revision shoulder arthroplasty: a large-scale bacterial whole-genome sequencing study. J Shoulder Elbow Surg 2024:S1058-2746(24)00241-6. [PMID: 38604398 DOI: 10.1016/j.jse.2024.02.039] [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: 01/10/2024] [Accepted: 02/24/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Cutibacterium acnes is the bacterium most commonly responsible for shoulder periprosthetic joint infection (PJI) and is often cultured from samples obtained at the time of revision for failed shoulder arthroplasty. We sought to determine whether these bacteria originate from the patient or from exogenous sources. We also sought to identify which C. acnes genetic traits were associated with the development of shoulder PJI. METHODS We performed bacterial whole-genome sequencing of C. acnes from a single-institution repository of cultures obtained before or during primary and revision shoulder arthroplasty and correlated the molecular epidemiology and genetic content of strains with clinical features of infection. RESULTS A total of 341 isolates collected over a 4-year period from 88 patients were sequenced. C. acnes cultured from surgical specimens demonstrated significant similarity to the strains colonizing the skin of the same patient (P < .001). Infrequently, there was evidence of strains shared across unrelated patients, suggesting that exogenous sources of C. acnes culture-positivity were uncommon. Phylotypes IB and II were modestly associated with clinical features of PJI, but all phylotypes appeared inherently capable of causing disease. Chronic shoulder PJI was associated with the absence of common C. acnes genes involved in bacterial quorum-sensing (luxS, tqsA). CONCLUSION C. acnes strains cultured from deep intraoperative sources during revision shoulder arthroplasty demonstrate strong genetic similarity to the strains colonizing a patient's skin. Some phylotypes of C. acnes commonly colonizing human skin are modestly more virulent than others, but all phylotypes have a capacity for PJI. C. acnes cultured from cases of PJI commonly demonstrated genetic hallmarks associated with adaptation from acute to chronic phases of infection. This is the strongest evidence to date supporting the role of the patient's own, cutaneous C. acnes strains in the pathogenesis of shoulder arthroplasty infection. Our findings support the importance of further research focused on perioperative decolonization and management of endogenous bacteria that are likely to be introduced into the arthroplasty wound at the time of skin incision.
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Affiliation(s)
- Jason E Hsu
- Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, WA, USA.
| | - Frederick A Matsen
- Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - Anastasia J Whitson
- Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - Adam Waalkes
- Department of Laboratory Medicine & Pathology, University of Washington Medical Center, Seattle, WA, USA
| | - Jared Almazan
- Department of Laboratory Medicine & Pathology, University of Washington Medical Center, Seattle, WA, USA
| | - Lori A Bourassa
- Department of Laboratory Medicine & Pathology, University of Washington Medical Center, Seattle, WA, USA
| | - Stephen J Salipante
- Department of Laboratory Medicine & Pathology, University of Washington Medical Center, Seattle, WA, USA
| | - Dustin R Long
- Department of Anesthesiology & Pain Medicine, University of Washington Medical Center, Seattle, WA, USA
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Lim C, Damasena I, Mclellan D, Kuster M. Use of thioglycolate broth as a pre-analytic transport medium in the diagnosis of prosthetic joint infection. Jt Dis Relat Surg 2024; 35:299-304. [PMID: 38727108 PMCID: PMC11128958 DOI: 10.52312/jdrs.2024.1364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 10/30/2023] [Indexed: 05/29/2024] Open
Abstract
OBJECTIVES This study aimed to investigate whether adding tissue samples directly into thioglycolate (TG) broth yielded a greater number of anaerobic organisms than freshly sampled tissue in suspected hip and knee prosthetic joint infections (PJIs). PATIENTS AND METHODS Between January 2017 and December 2020, a total of 90 patients (46 males, 44 females; median age: 71.7 years; range, 50.8 and 87.8 years) who underwent revision hip or knee arthroplasty were included. Intraoperative samples were taken, with five placed in TG broth and five in standard containers (PC) with subsequent aerobic and anaerobic culturing conducted. Demographic and baseline data of the patients were recorded. The primary outcome was positive bacterial growth from a PJI specimen inoculated directly into TG broth at the time of collection or standard PJI specimen processing. Secondary outcomes investigated were the presence of Cutibacterium acnes (C. acnes) and the curative success of revision procedure. RESULTS A total of 900 samples (450 PC and 450 TG) were taken from 90 revision arthroplasty patients (47 knees and 43 hips). There was no statistically significant difference in the number of positive bacterial growth samples between TG broth and standard processing (p=0.742). This was consistent with subgroup analysis analyzing C. acnes (p=0.666). CONCLUSION In hip and knee arthroplasty, there is no benefit in substituting or adding TG broth as a culture medium to better identify both general bacterial species and C. acnes infections specifically. However, the use of TG may be useful in confirming a true positive result for infection.
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Affiliation(s)
- Christopher Lim
- Fiona Stanley Hospital, 11 Robin Warren Dr, Murdoch, WA, 6150, Australia.
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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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Hsu JE, Whitson AJ, Van Dyke R, Wu JC, Matsen FA, Long DR. Dynamics of Cutibacterium repopulation onto the skin surface of the shoulder after chlorhexidine application. INTERNATIONAL ORTHOPAEDICS 2023; 47:1511-1515. [PMID: 36977799 PMCID: PMC10694997 DOI: 10.1007/s00264-023-05786-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 03/17/2023] [Indexed: 03/30/2023]
Abstract
PURPOSE The objective of this study was to characterize the temporal dynamics of Cutibacterium repopulation of the skin surface after application of chlorhexidine to the shoulder. METHODS Ten shoulders in five male subjects were used. A skin swab was taken prior to (0 minutes) and then at three, 30, 60, 120, and 240 minutes after skin preparation with 2% chlorhexidine gluconate and 70% isopropyl alcohol. Semi-quantitative bacterial load was measured for each timepoint. RESULTS From zero minutes (pre-treatment) to three minutes, chlorhexidine-isopropyl alcohol reduced the skin bacterial load in eight out of ten shoulders. Of these eight shoulders, four (50%) had growth by 30 minutes, seven (88%) had growth by 60 minutes, and all eight (100%) had growth by 240 minutes. Compared to the three minutes after chlorhexidine application, bacterial load had significantly increased by 60 minutes but were still significantly lower than the pre-prep bacterial load (0 minutes). CONCLUSION Following standard surgical skin preparation with chlorhexidine-isopropyl alcohol, the surface of the shoulder is repopulated with Cutibacterium within one hour, presumably from reservoirs in sebaceous glands not penetrated by topical antiseptic agents. Since these dermal glands are transected by skin incision for shoulder arthroplasty, this study suggests that they may be sources of wound contamination during surgery in spite of skin preparation with chlorhexidine.
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Affiliation(s)
- Jason E Hsu
- Investigation Performed at the University of Washington, Department of Orthopedics and Sports Medicine, Seattle, WA, USA.
| | - Anastasia J Whitson
- Investigation Performed at the University of Washington, Department of Orthopedics and Sports Medicine, Seattle, WA, USA
| | - Rufus Van Dyke
- Investigation Performed at the University of Washington, Department of Orthopedics and Sports Medicine, Seattle, WA, USA
| | - John C Wu
- Investigation Performed at the University of Washington, Department of Orthopedics and Sports Medicine, Seattle, WA, USA
| | - Frederick A Matsen
- Investigation Performed at the University of Washington, Department of Orthopedics and Sports Medicine, Seattle, WA, USA
| | - Dustin R Long
- Harborview Medical Center Department of Anesthesiology and Pain Medicine Division of Critical Care Medicine, University of Washington, 325 9th Avenue, Seattle, WA, 98104, USA
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Ponraj DS, Lund M, Lange J, Poehlein A, Himmelbach A, Falstie-Jensen T, Jørgensen NP, Ravn C, Brüggemann H. Shotgun sequencing of sonication fluid for the diagnosis of orthopaedic implant-associated infections with Cutibacterium acnes as suspected causative agent. Front Cell Infect Microbiol 2023; 13:1165017. [PMID: 37265503 PMCID: PMC10229904 DOI: 10.3389/fcimb.2023.1165017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 05/02/2023] [Indexed: 06/03/2023] Open
Abstract
Orthopaedic implant-associated infections (OIAIs) due to Cutibacterium acnes can be difficult to diagnose. The aim of this pilot study was to determine if metagenomic next-generation sequencing (mNGS) can provide additional information to improve the diagnosis of C. acnes OIAIs. mNGS was performed on sonication fluid (SF) specimens derived from 24 implants. These were divided into three groups, based on culture results: group I, culture-negative (n = 4); group II, culture-positive for C. acnes (n = 10); and group III, culture-positive for other bacteria (n = 10). In group I, sequence reads from C. acnes were detected in only one SF sample, originating from a suspected case of OIAIs, which was SF and tissue culture-negative. In group II, C. acnes sequences were detected in 7/10 samples. In group III, C. acnes sequence reads were found in 5/10 samples, in addition to sequence reads that matched the bacterial species identified by culture. These samples could represent polymicrobial infections that were missed by culture. Taken together, mNGS was able to detect C. acnes DNA in more samples compared to culture and could be used to identify cases of suspected C. acnes OIAIs, in particular regarding possible polymicrobial infections, where the growth of C. acnes might be compromised due to a fast-growing bacterial species. However, since SF specimens are usually low-biomass samples, mNGS is prone to DNA contamination, possibly introduced during DNA extraction or sequencing procedures. Thus, it is advisable to set a sequence read count threshold, taking into account project- and NGS-specific criteria.
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Affiliation(s)
| | - Michael Lund
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Jeppe Lange
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Orthopaedic Surgery, Regional Hospital, Horsens, Denmark
| | - Anja Poehlein
- Department of Genomic and Applied Microbiology, Institute of Microbiology and Genetics, University of Göttingen, Göttingen, Germany
| | - Axel Himmelbach
- Leibniz Institute of Plant Genetics and Crop Plant Research (IPK), Gatersleben, Germany
| | | | | | - Christen Ravn
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
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García-Pérez D, García-Posadas G, San-Juan R, Brañas P, Panero-Pérez I, Delgado-Fernández J, Paredes I. A prospective study to identify preoperative serum parameters for spinal implant infection detected by sonication fluid culture. 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 2023; 32:1818-1829. [PMID: 36897428 DOI: 10.1007/s00586-023-07628-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/03/2023] [Accepted: 02/23/2023] [Indexed: 03/11/2023]
Abstract
PURPOSE Low-virulent microorganisms identified on pedicle screws by sonication fluid culture (SFC) are an important cause of implant loosening. While sonication of explanted material improves the detection rate, the risk of contamination exists and no standardized diagnostic criteria for chronic low-grade spinal implant-related infection (CLGSII) are stablished. Besides, the role of serum C-reactive protein (CRP) and procalcitonin (PCT) in CLGSII has not been adequately investigated. METHODS Blood samples were collected prior to implant removal. To increase sensitivity, the explanted screws were sonicated and processed separately. Patients exhibiting at least one positive SFC were classified in the infection group (loose criteria). To increase specificity, the strict criteria only considered multiple positive SFC (≥ 3 implants and/or ≥ 50% of explanted devices) as meaningful for CLGSII. Factors which might promote implant infection were also recorded. RESULTS Thirty-six patients and 200 screws were included. Among them, 18 (50%) patients had any positive SFCs (loose criteria), whereas 11 (31%) patients fulfilled the strict criteria for CLGSII. Higher serum protein level was the most accurate marker for the preoperative detection of CLGSSI, exhibiting an area under the curve of 0.702 (loose criteria) and 0.819 (strict criteria) for the diagnosis of CLGSII. CRP only exhibited a modest accuracy, whereas PCT was not a reliable biomarker. Patient history (spinal trauma, ICU hospitalization and/or previous wound-related complications) increased the likelihood of CLGSII. CONCLUSION Markers of systemic inflammation (serum protein level) and patient history should be employed to stratify preoperative risk of CLGSII and decide the best treatment strategy.
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Affiliation(s)
- Daniel García-Pérez
- Department of Neurosurgery, University Hospital, 12 de Octubre, Avda de Córdoba S/N, 28041, Madrid, Spain.
- Department of Neurosurgery, Complejo Universitario Hospital Albacete, Calle Hermanos Falcó 37, 02008, Albacete, Spain.
| | - Guillermo García-Posadas
- Department of Neurosurgery, University Hospital, 12 de Octubre, Avda de Córdoba S/N, 28041, Madrid, Spain
| | - Rafael San-Juan
- Unit of Infectious Diseases, University Hospital, 12 de Octubre, Avda de Córdoba S/N, 28041, Madrid, Spain
| | - Patricia Brañas
- Department of Clinical Microbiology, University Hospital, 12 de Octubre, Avda de Córdoba S/N, 28041, Madrid, Spain
| | - Irene Panero-Pérez
- Department of Neurosurgery, University Hospital, 12 de Octubre, Avda de Córdoba S/N, 28041, Madrid, Spain
| | - Juan Delgado-Fernández
- Department of Neurosurgery, University Hospital, 12 de Octubre, Avda de Córdoba S/N, 28041, Madrid, Spain
| | - Igor Paredes
- Department of Neurosurgery, University Hospital, 12 de Octubre, Avda de Córdoba S/N, 28041, Madrid, Spain
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Schiffman CJ, Jurgensmeier K, Yao JJ, Wu JC, Whitson AJ, Jackins SE, Matsen FA, Hsu JE. Risk Factors for Stiffness Requiring Intervention After Ream-and-Run Arthroplasty. JB JS Open Access 2023; 8:e22.00104. [PMID: 37123506 PMCID: PMC10132725 DOI: 10.2106/jbjs.oa.22.00104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
Ream-and-run arthroplasty can improve pain and function in patients with glenohumeral arthritis while avoiding the complications and activity restrictions associated with a prosthetic glenoid component. However, stiffness is a known complication after ream-and-run arthroplasty and can lead to repeat procedures such as a manipulation under anesthesia (MUA) or open surgical revision. The objective of this study was to determine risk factors associated with repeat procedures indicated for postoperative stiffness after ream-and-run arthroplasty. Methods We conducted a retrospective review of our shoulder arthroplasty database to identify patients who underwent ream-and-run arthroplasty and determined which patients underwent subsequent repeat procedures (MUA and/or open revision) indicated for postoperative stiffness. The minimum follow-up was 2 years. We collected baseline demographic information and preoperative and 2-year patient-reported outcome scores and analyzed preoperative radiographs. Univariate and multivariate analyses determined the factors significantly associated with repeat procedures to treat postoperative stiffness. Results There were 340 patients who underwent ream-and-run arthroplasty. The mean Simple Shoulder Test (SST) scores for all patients improved from 5.0 ± 2.4 preoperatively to 10.2 ± 2.6 postoperatively (p < 0.001). Twenty-six patients (7.6%) underwent open revision for stiffness. An additional 35 patients (10.3%) underwent MUA. Univariate analysis found younger age (p = 0.001), female sex (p = 0.034), lower American Society of Anesthesiologists (ASA) class (p = 0.045), posterior decentering on preoperative radiographs (p = 0.010), and less passive forward elevation at the time of discharge after ream-and-run arthroplasty (p < 0.001) to be significant risk factors for repeat procedures. Multivariate analysis found younger age (p = 0.040), ASA class 1 compared with class 3 (p = 0.020), and less passive forward elevation at discharge (p < 0.001) to be independent risk factors for repeat procedures. Of the patients who underwent open revision for stiffness, 69.2% had multiple positive cultures for Cutibacterium. Conclusions Younger age, ASA class 1 compared with class 3, and less passive forward elevation in the immediate postoperative period were independent risk factors for repeat procedures to treat postoperative stiffness after ream-and-run arthroplasty. Level of Evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Corey J. Schiffman
- Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, Washington
| | | | - Jie J. Yao
- Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, Washington
| | - John C. Wu
- Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, Washington
| | - Anastasia J. Whitson
- Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, Washington
| | - Sarah E. Jackins
- Exercise Training Center, University of Washington, Seattle, Washington
| | - Frederick A. Matsen
- Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, Washington
| | - Jason E. Hsu
- Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, Washington
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13
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Peng G, Liu Q, Guan Z, Liu M, Sun X, Zhu X, Chen J, Feng W, Li J, Zeng J, Zhong Z, Zeng Y. Diagnostic accuracy of sonication fluid cultures from prosthetic components in periprosthetic joint infection: an updated diagnostic meta-analysis. J Orthop Surg Res 2023; 18:175. [PMID: 36890571 PMCID: PMC9996915 DOI: 10.1186/s13018-023-03662-3] [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: 02/11/2022] [Accepted: 02/27/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) is the most serious complication following total joint arthroplasty (TJA) and has a significant impact on patients and the national healthcare system. To date, the diagnosis of PJI is still confronted with dilemmas. The present study investigated the validity of sonication fluid culture (SFC) for removing implants in the diagnosis of PJI after joint replacement. METHODS From database establishment to December 2020, relevant literature was retrieved from the PubMed, Web of Science, Embase and Cochrane Library databases. Two reviewers independently performed quality assessment and data extraction to calculate the pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), area under the curve (AUC) and diagnostic odds ratio (DOR) to evaluate the diagnostic value of overall SFC for PJI. RESULTS A total of 38 eligible studies including 6302 patients were selected in this study. The pooled sensitivity, specificity, PLR, NLR, and DOR of SFC for PJI diagnosis were 0.77 (95% confidence interval [CI], 0.76-0.79), 0.96 (95% CI, 0.95-0.96), 18.68 (95% CI, 11.92-29.28), 0.24 (95% CI, 0.21-0.29), and 85.65 (95% CI, 56.46-129.94), respectively, while the AUC was 0.92. CONCLUSION This meta-analysis showed that SFC was of great value in PJI diagnosis, and the evidence of SFC on PJI was more favorable but not yet strong. Therefore, improvement of the diagnostic accuracy of SFC is still necessary, and the diagnosis of PJI continues to warrant a multiplex approach before and during a revision procedure.
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Affiliation(s)
- Guanrong Peng
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, People's Republic of China.,Yudu People's Hospital, Huancheng North Road 2#, District Yudu, Ganzhou, 342300, Jiangxi, People's Republic of China
| | - Qiang Liu
- Peking University People's Hospital, Arthritis Clinic and Research Center, Beijing, People's Republic of China
| | - Zhenhua Guan
- Yudu People's Hospital, Huancheng North Road 2#, District Yudu, Ganzhou, 342300, Jiangxi, People's Republic of China
| | - Min Liu
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, People's Republic of China
| | - Xiaobo Sun
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, People's Republic of China
| | - Xingyang Zhu
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, People's Republic of China
| | - Jinlun Chen
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, People's Republic of China
| | - Wenjun Feng
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, People's Republic of China
| | - Jie Li
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, People's Republic of China
| | - Jianchun Zeng
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, People's Republic of China
| | - Zhangrong Zhong
- Yudu People's Hospital, Huancheng North Road 2#, District Yudu, Ganzhou, 342300, Jiangxi, People's Republic of China.
| | - Yirong Zeng
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, People's Republic of China.
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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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Sigmund IK, Yeghiazaryan L, Luger M, Windhager R, Sulzbacher I, McNally MA. Three to six tissue specimens for histopathological analysis are most accurate for diagnosing periprosthetic joint infection. Bone Joint J 2023; 105-B:158-165. [PMID: 36722061 DOI: 10.1302/0301-620x.105b2.bjj-2022-0859.r1] [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] [Indexed: 02/02/2023]
Abstract
AIMS The aim of this study was to evaluate the optimal deep tissue specimen sample number for histopathological analysis in the diagnosis of periprosthetic joint infection (PJI). METHODS In this retrospective diagnostic study, patients undergoing revision surgery after total hip or knee arthroplasty (n = 119) between January 2015 and July 2018 were included. Multiple specimens of the periprosthetic membrane and pseudocapsule were obtained for histopathological analysis at revision arthroplasty. Based on the Infectious Diseases Society of America (IDSA) 2013 criteria, the International Consensus Meeting (ICM) 2018 criteria, and the European Bone and Joint Infection Society (EBJIS) 2021 criteria, PJI was defined. Using a mixed effects logistic regression model, the sensitivity and specificity of the histological diagnosis were calculated. The optimal number of periprosthetic tissue specimens for histopathological analysis was determined by applying the Youden index. RESULTS Based on the EBJIS criteria (excluding histology), 46 (39%) patients were classified as infected. Four to six specimens showed the highest Youden index (four specimens: 0.631; five: 0.634; six: 0.632). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of five tissue specimens were 76.5% (95% confidence interval (CI) 67.6 to 81.4), 86.8% (95% CI 81.3 to 93.5), 66.0% (95% CI 53.2 to 78.7), and 84.3% (95% CI 79.4 to 89.3), respectively. The area under the curve (AUC) was calculated with 0.81 (as a function of the number of tissue specimens). Applying the ICM and IDSA criteria (excluding histology), 40 (34%) and 32 (27%) patients were categorized as septic. Three to five specimens had the highest Youden index (ICM 3: 0.648; 4: 0.651; 5: 0.649) (IDSA 3: 0.627; 4: 0.629; 5: 0.625). CONCLUSION Three to six tissue specimens of the periprosthetic membrane and pseudocapsule should be collected at revision arthroplasty and analyzed by a pathologist experienced and skilled in interpreting periprosthetic tissue.Cite this article: Bone Joint J 2023;105-B(2):158-165.
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Affiliation(s)
- Irene K Sigmund
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Lusine Yeghiazaryan
- Medical University of Vienna, Centre for Medical Statistics, Informatics and Intelligent Systems, Institute of Medical Statistics, Vienna, Austria
| | - Markus Luger
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Reinhard Windhager
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Irene Sulzbacher
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Martin A McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
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Kloos J, Vander Linden K, Vermote S, Berger P, Vandenneucker H. Prevalence, interpretation, and management of unexpected positive cultures in revision TKA: a systematic review. Knee Surg Sports Traumatol Arthrosc 2022; 30:3998-4009. [PMID: 35031821 DOI: 10.1007/s00167-021-06856-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 12/21/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Unexpected positive intraoperative cultures (UPIC) found in revision total knee arthroplasty (TKA) are difficult to interpret. Management goes along with risks for both over- and undertreating a potential periprosthetic joint infection (PJI). The objective of this systematic review was to determine the prevalence of UPIC in revision TKA surgery, evaluate the diagnostic workup process and the postoperative treatment, and assess outcome regarding re-revision rates. METHODS Evidence was gathered from Medline (PubMed) and Embase published from January 2000 until April 2021. Nine studies with data of UPIC in revision TKA and outcome after at least 2 years of follow-up were identified. RESULTS The calculated prevalence of UPIC in aseptic knee revision surgery was 8.32%. However, the diagnostical approach differs as well as the used criteria to confirm PJI in presumed aseptic revision surgery. The work-up generally consists of a serum C-reactive protein and Erythrocyte Sedimentation Rate, joint fluid aspiration for culture and white blood cell count and formula, and radiographic imaging. Collection of intraoperative cultures is widely used, but inconsistent in sample amount and incubation time. Once a single UPIC is found, surgeons tend to treat it in different ways. Regarding re-revision rates, the weighted arithmetic mean in the included studies was 18.45% in the unsuspected PJI group compared to 2.94% in the aseptic group. There also seems to be a trend towards higher re-revision rates when a higher number of intraoperative cultures are positive. CONCLUSION The interpretation of UPIC in revision TKA is of utmost importance since the decision whether to treat a UPIC as an unsuspected PJI has a major impact on implant survival and re-revision rate. Different criteria are used to differentiate between unsuspected PJI and contamination in true aseptic failure, and the heterogeneity amongst the included papers impedes to state a clear recommendation, integrating not only quantitative findings, but also qualitative data such as virulence of the identified microorganism. LEVEL OF EVIDENCE Systematic review, III.
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Affiliation(s)
- Johannes Kloos
- Department of Orthopaedic Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Koen Vander Linden
- Department of Orthopaedic Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Stijn Vermote
- Department of Orthopaedic Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Pieter Berger
- Department of Orthopaedic Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Hilde Vandenneucker
- Department of Orthopaedic Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
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The Prevalence and Outcomes of Unexpected Positive Intraoperative Cultures in Presumed Aseptic Revision Knee Arthroplasty. J Arthroplasty 2022; 37:2262-2271. [PMID: 35598759 DOI: 10.1016/j.arth.2022.05.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 05/11/2022] [Accepted: 05/16/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The prevalence and outcomes of unexpected positive intraoperative cultures (UPC) in presumed aseptic revision total knee arthroplasty (TKA) are unclear. The purpose of this study was to determine the prevalence of UPC and infection-free implant survival in this patient population. Secondly, we aimed to compare the infection-free implant survival between cohorts based on number of UPCs and antibiotic treatment. METHODS We reviewed our institutional database from 2006 to 2019 for all TKA revisions (n = 1795) to identify all presumed aseptic TKA revisions with intraoperative culture(s). After exclusions, 775 revisions were eligible and those with UPC were included in the Kaplan-Meier analysis to determine infection-free implant survival for the cohorts. RESULTS The prevalence of UPC was 9.8%. The 2- and 5-year infection-free survival was 97.4% and 95.3%, respectively. The 5-year infection-free survival from the same microorganism as the UPC was 98.7%. Infection-free survival was similar for the 1 versus ≥2 UPC cohorts (P = .416), however was poorer for the cohort treated with antibiotics (P = .021). Only one of 3 subsequent PJI-related implant failures was caused by the same microorganism (polymicrobial) as the UPC. There were no subsequent infections in patients with a single UPC not treated with antibiotics. CONCLUSIONS The prevalence of UPC was 9.8% and the infection-free implant survival is excellent. Infection-free survivorship from PJI caused by the same UPC microorganism is outstanding. Comparisons between cohorts must be interpreted with caution due to study limitations. A single UPC in patents without other signs of infection does not require antibiotic treatment. LEVEL OF EVIDENCE IV.
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18
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An evidence-based approach to managing unexpected positive cultures in shoulder arthroplasty. J Shoulder Elbow Surg 2022; 31:2176-2186. [PMID: 35513254 DOI: 10.1016/j.jse.2022.03.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 03/11/2022] [Accepted: 03/21/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Unexpected positive cultures (UPCs) are very commonly found during shoulder arthroplasty when surgeons send intraoperative cultures to rule out periprosthetic joint infection (PJI) without clinical or radiographic signs of infection. Cutibacterium acnes is thought to be the most common bacteria cultured in this setting; however, the implications of an unexpected positive result are neither well defined nor agreed upon within the literature. The current review evaluates the incidence of UPCs and C acnes in reverse total arthroplasty; the clinical significance, if any, of these cultures; and various prognostic factors that may affect UPC incidence or recovery following PJI. METHODS A systematic review was performed with PRISMA guidelines using PubMed, CINAHL, and Scopus databases. Inclusion criteria included studies published from January 1, 2000, to May 20, 2021, that specifically reported on UPCs, native or revision shoulder surgery, and any study that directly addressed one of our 6 proposed clinical questions. Two independent investigators initially screened 267 articles for further evaluation. Data on study design, UPC rate/speciation, UPC risk factors, and UPC outcomes were analyzed and described. RESULTS A total of 22 studies met the inclusion criteria for this study. There was a pooled rate of 27.5% (653/2373) deep UPC specimen positivity, and C acnes represented 76.4% (499/653) of these positive specimens. Inanimate specimen positivity was reported at a pooled rate of 20.1% (29/144) across 3 studies. Male patients were more likely to have a UPC; however, the significance of prior surgery, surgical approach, and type of surgery conflicted across multiple articles. Patient-reported outcomes and reoperation rates did not differ between positive-UPC and negative-UPC patients. The utilization of antibiotics and treatment regimen varied across studies; however, the reinfection rates following surgery did not statistically differ based on the inclusion of antibiotics. CONCLUSION UPCs are a frequent finding during shoulder surgery and C acnes represents the highest percentage of cultured bacteria. Various preoperative risk factors, surgical techniques, and postoperative treatment regimens did not significantly affect the incidence of UPCs as well as the clinical outcomes for UPC vs. non-UPC patients. A standardized protocol for treatment and follow-up would decrease physician uncertainty when faced with a UPC from shoulder surgery. Given the results of this review, shoulder surgeons can consider not drastically altering the postoperative clinical course in the setting of UPC with no other evidence of PJI.
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Nhan DT, Gong DC, Khoo KJ, Whitson AJ, Matsen FA, Hsu JE. Culturing explants for Cutibacterium at revision shoulder arthroplasty: an analysis of explant and tissue samples at corresponding anatomic sites. J Shoulder Elbow Surg 2022; 31:2017-2022. [PMID: 35447317 DOI: 10.1016/j.jse.2022.03.004] [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: 07/03/2021] [Revised: 02/22/2022] [Accepted: 03/06/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Culturing of deep tissues obtained at revision arthroplasty for Cutibacterium is a key component of diagnosing a periprosthetic infection. The value of culturing explanted components has not been well described. This study sought to answer the following questions: (1) How does the culture positivity of explant cultures compare with that of deep tissue cultures? (2) How often are explant cultures positive when tissue cultures are not, and vice versa? (3) How does the bacterial density in explant cultures compare with that in tissue cultures? METHODS A total of 106 anatomic arthroplasties revised over a 7-year period were included. Explant (humeral head, humeral stem, and glenoid) and tissue (collar membrane, humeral canal tissue, and periglenoid tissue) specimens were sent for semiquantitative Cutibacterium culture. We compared culture positivity and bacterial density when cultures of an explant and tissue adjacent to the implant were both available. RESULTS Explants had positive cultures at a higher rate than adjacent tissue specimens for most anatomic sites. Of the shoulders that had Cutibacterium growth, a higher proportion of explants were culture positive when tissue samples were negative (23%-43%) than vice versa (0%-21%). The Cutibacterium density was higher in explants than in tissues. Considering only the results of tissue samples, 16% of the shoulders met our threshold for infection treatment (≥2 positive cultures); however, with the inclusion of the results for explant cultures, additional 14% of cases-a total of 30%-met the criteria for infection treatment. CONCLUSIONS In this group of patients, culturing explants in addition to tissue cultures increased the sensitivity for detecting Cutibacterium in revision shoulder arthroplasty.
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Affiliation(s)
- Derek T Nhan
- Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - Davin C Gong
- Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - Kevin J Khoo
- Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - Anastasia J Whitson
- Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - Frederick A Matsen
- Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - Jason E Hsu
- Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, WA, USA.
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Egbulefu FJ, Yang J, Segreti JC, Sporer SM, Chen AF, Austin MS, Della Valle CJ. Recurrent Failures After 2-Stage Exchanges are Secondary to New Organisms Not Previously Covered by Antibiotics. Arthroplast Today 2022; 17:186-191.e1. [PMID: 36254212 PMCID: PMC9568676 DOI: 10.1016/j.artd.2022.07.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 07/01/2022] [Accepted: 07/26/2022] [Indexed: 10/29/2022] Open
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21
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Hsu JE, Bumgarner RE, Bourassa LA, Budge MD, Duquin TR, Garrigues GE, Green A, Iannotti JP, Khazzam MS, Koh JL, Matsen FA, Namdari S, Nicholson TA, Richter SS, Sabesan VJ, Virk MS, Whitson AJ, Yian EH, Ricchetti ET. What do positive and negative Cutibacterium culture results in periprosthetic shoulder infection mean? A multi-institutional control study. J Shoulder Elbow Surg 2022; 31:1713-1720. [PMID: 35176494 DOI: 10.1016/j.jse.2022.01.127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 01/06/2022] [Accepted: 01/09/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Deep tissue culture specimens obtained at the time of revision shoulder arthroplasty are commonly positive for Cutibacterium. Clinical interpretation of positive cultures can be difficult. This was a multi-institutional study evaluating the accuracy of cultures for Cutibacterium using positive control (PC) and negative control (NC) samples. The relationship between time to culture positivity and strength of culture positivity was also studied. METHODS Eleven different institutions were each sent 12 blinded samples (10 PC and 2 NC samples). The 10 PC samples included 2 sets of 5 different dilutions of a Cutibacterium isolate from a failed total shoulder arthroplasty with a probable periprosthetic infection. At each institution, the samples were handled as if they were received from the operating room. Specimen growth, time to culture positivity, and strength of culture positivity (based on semiquantitative assessment) were reported. RESULTS A total of 110 PC samples and 22 NC samples were tested. One hundred percent of specimens at the 4 highest dilutions were positive for Cutibacterium. At the lowest dilution, 91% of samples showed positive findings. Cutibacterium grew in 14% of NC samples. Cutibacterium grew in PC samples at an average of 4.0 ± 1.3 days, and all of these samples showed growth within 7 days. The time to positivity was significantly shorter (P < .001) and the strength of positivity was significantly higher (P < .001) in true-positive cultures compared with false-positive cultures. CONCLUSIONS This multi-institutional study suggests that different institutions may report highly consistent rates of culture positivity for revision shoulder arthroplasty samples with higher bacterial loads. In contrast, with lower bacterial loads, the results are somewhat less consistent. Clinicians should consider using a shorter time to positivity and a higher strength of positivity as adjuncts in determining whether a tissue culture sample is a true positive.
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Affiliation(s)
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- ASES PJI Multicenter Research Group
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22
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Bohard L, Patry I, Sergent P, Leclerc G, Leroy J, Chirouze C, Bouiller K. Factors associated with late microbiological documentation of prosthetic joint infection. Future Microbiol 2022; 17:1115-1124. [PMID: 35860979 DOI: 10.2217/fmb-2021-0310] [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: 11/21/2022] Open
Abstract
Purpose: To describe the number of prosthetic joint infections (PJIs) with late documentation and to identify associated factors. Methods: Bacterial PJIs with surgical management between November 2015 and November 2019 in a French center were analyzed. Results of short (72 h) and late culture (at 14 days) were analyzed. Results: A total of 160 PJIs were reported with 215 bacteria. Twenty-nine patients had late documentation (18.1%). The bacteria most involved were coagulase-negative staphylococci and Cutibacterium spp. (60%). In multivariate analysis, late chronic PJI (odds ratio = 2.47) and antibiotic therapy before surgery (odds ratio = 3.13) were associated with late-documented infection. Conclusion: A better knowledge of the factors associated with late-documented infections is essential in order to simplify antibiotic treatment at the appropriate time.
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Affiliation(s)
- Louis Bohard
- Department of Infectious Diseases, CHU Besancon, Besancon, 25000, France
| | - Isabelle Patry
- Department of Bacteriology, CHU Besancon, Besancon, 25000, France
| | - Pauline Sergent
- Department of Orthopedic, Trauma, Plastic & Reconstructive Surgery & Hand Clinic, CHU Besancon, Besancon, 25000, France
| | - Grégoire Leclerc
- Department of Orthopedic, Trauma, Plastic & Reconstructive Surgery & Hand Clinic, CHU Besancon, Besancon, 25000, France
| | - Joël Leroy
- Department of Infectious Diseases, CHU Besancon, Besancon, 25000, France
| | - Catherine Chirouze
- Department of Infectious Diseases, CHU Besancon, Besancon, 25000, France.,UMR-CNRS 6249 Chrono-Environnement, Université Bourgogne Franche-Comté, Besancon, Besancon, 25000, France
| | - Kevin Bouiller
- Department of Infectious Diseases, CHU Besancon, Besancon, 25000, France.,UMR-CNRS 6249 Chrono-Environnement, Université Bourgogne Franche-Comté, Besancon, Besancon, 25000, France
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23
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Fast and Sensitive Multiplex Real-Time Quantitative PCR to Detect Cutibacterium Periprosthetic Joint Infections. J Mol Diagn 2022; 24:666-673. [PMID: 35364323 DOI: 10.1016/j.jmoldx.2022.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 01/31/2022] [Accepted: 03/04/2022] [Indexed: 12/26/2022] Open
Abstract
Diagnosis of Cutibacterium periprosthetic joint infections (PJIs) is challenging due to a long cultivation time of up to 14 days. Faster culture-independent diagnosis would improve patient care with early and accurate treatment. Specific primers and probes were designed for Cutibacterium acnes, Cutibacterium avidum, and Cutibacterium granulosum and evaluated in a multiplex TaqMan real-time quantitative PCR (qPCR) format on 57 skin swabs and 20 culture-negative cerebrospinal fluid samples. The multiplex qPCR was tested in a PJI cohort of 41 sonication fluid samples from removed implants infected with different pathogens. All five culture-positive Cutibacterium PJIs were detected with the corresponding Cutibacterium-specific probe (100% positive percent agreement). The multiplex qPCR additionally detected C. avidum in two PJI sonication fluid samples that were diagnosed as Staphylococcus species infections according to culture (95% negative percent agreement). The new multiplex qPCR can provide a Cutibacterium PJI diagnosis within 1 day, allowing early and accurate antibiotic treatment. A prospective diagnostic trial in PJI with a high number of Cutibacterium species infections (shoulder PJI) is needed for further evaluation.
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24
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Positivity Trends of Bacterial Cultures from Cases of Acute and Chronic Periprosthetic Joint Infections. J Clin Med 2022; 11:jcm11082238. [PMID: 35456331 PMCID: PMC9030751 DOI: 10.3390/jcm11082238] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 03/27/2022] [Accepted: 04/14/2022] [Indexed: 01/27/2023] Open
Abstract
Background: There is no clear distinction in the literature regarding the positivity trends of bacterial cultures in acute and chronic prosthetic joint infections. Methods: We prospectively included in this study all consecutive patients, aged over 18 years, that were hospitalized from September 2016 through December 2019, that underwent a joint arthroplasty revision surgery. Results: Forty patients were included in our analysis, 11 acute/acute hematogenous and 29 chronic PJIs. We were able to identify all strains of acute/acute hematogenous PJIs within 3 days, whereas this took 8 days for chronic PJIs. Sonication fluid cultures increased the positivity rate and helped in identifying rare pathogens such as Ralstonia pickettii from chronic PJIs, but also increased the number of identified strains from acute PJIs. Culturing synovial fluid in our study did not seem to have a clear benefit compared to sonication fluid and periprosthetic tissue cultures. Conclusion: There was a different positivity trend in bacterial cultures. Empiric broad-spectrum antibiotic therapy can be re-evaluated after 3 days for acute PJIs. A prolonged incubation time, especially in the case of chronic PJIs, is mandatory; however, extending the incubation period beyond 14 days would not further improve the ability to identify microorganisms.
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25
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Ponraj DS, Lange J, Falstie-Jensen T, Jørgensen NP, Ravn C, Poehlein A, Brüggemann H. Amplicon-Based Next-Generation Sequencing as a Diagnostic Tool for the Detection of Phylotypes of Cutibacterium acnes in Orthopedic Implant-Associated Infections. Front Microbiol 2022; 13:866893. [PMID: 35464945 PMCID: PMC9022064 DOI: 10.3389/fmicb.2022.866893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/21/2022] [Indexed: 01/04/2023] Open
Abstract
The diagnosis of orthopedic implant-associated infections (OIAIs) caused by the slow-growing anaerobic bacterium Cutibacterium acnes is challenging. The mild clinical presentations of this low-virulent bacterium along with its ubiquitous presence on human skin and human-dominated environments often make it difficult to differentiate true infection from contamination. Previous studies have applied C. acnes phylotyping as a potential avenue to distinguish contamination from infection; several studies reported a prevalence of phylotypes IB [corresponding to type H in the single-locus sequence typing (SLST) scheme] and II (SLST type K) in OIAIs, while a few others found phylotype IA1 (more specifically SLST type A) to be abundant. However, phylotype determination has mainly been done in a culture-dependent manner on randomly selected C. acnes isolates. Here, we used a culture-independent amplicon-based next-generation sequencing (aNGS) approach to determine the presence and relative abundances of C. acnes phylotypes in clinical OIAI specimens. As amplicon, the SLST target was used, a genomic fragment that is present in all C. acnes strains known to date. The aNGS approach was applied to 30 sonication fluid (SF) samples obtained from implants removed during revision surgeries, including 17 C. acnes culture-positive and 13 culture-negative SF specimens. In 53% of the culture-positive samples, SLST types were identified: relative abundances were highest for K-type C. acnes, followed by H- and D-type C. acnes. Other types, including A- and C-type C. acnes that are more prevalent on human skin, had low relative abundances. The aNGS results were compared with, and confirmed by a culture-dependent approach, which included the isolation, whole genome sequencing (WGS) and phylotyping of 36 strains of C. acnes obtained from these SF samples. Besides serving as a powerful adjunct to identify C. acnes phylotypes, the aNGS approach could also distinguish mono- from heterotypic infections, i.e., infections caused by more than one phylotype of C. acnes: in eight out of nine culture-positive SF samples multiple C. acnes types were detected. We propose that the aNGS approach, along with the patient's clinical information, tissue and SF cultures and WGS, could help differentiate C. acnes contamination from true infection.
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Affiliation(s)
| | - Jeppe Lange
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Orthopedic Surgery, Horsens Regional Hospital, Horsens, Denmark
| | | | | | - Christen Ravn
- Department of Orthopedic Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Orthopedic Surgery, Lillebaelt Hospital, Kolding, Denmark
| | - Anja Poehlein
- Department of Genomic and Applied Microbiology, Institute of Microbiology and Genetics, University of Göttingen, Göttingen, Germany
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26
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Skura B, Glazier MT, Schuette HB, Passias BJ, Chang IR, Verre J, Mehta S, Taylor BC. The Corkscrew Technique for Removing a Fibular Strut Allograft From the Proximal Humerus. Cureus 2022; 14:e23233. [PMID: 35449668 PMCID: PMC9012660 DOI: 10.7759/cureus.23233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2022] [Indexed: 11/05/2022] Open
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27
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Palmer MP, Altman DT, Altman GT, Sewecke JJ, Saltarski C, Nistico L, Melton-Kreft R, Hu FZ, Ehrlich GD. Bacterial Identification and Visualization of Bacterial Biofilms Adjacent to Fracture Sites After Internal Fixation. Genet Test Mol Biomarkers 2022; 26:70-80. [PMID: 35225678 DOI: 10.1089/gtmb.2019.0225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objectives: The primary aims of this study were to determine if any correlation exists in cases of fracture fixation among: (1) bacterial profiles recovered from the instrumentation and adjacent tissues; (2) the type of orthopedic injury; and (3) the clinical outcome-union versus nonunion. A secondary goal was to compare culture and molecular diagnostics for identifying the bacterial species present following fracture fixation. Design: Single-institution, prospective case-control cohort study. Setting: Single level 1 trauma center. Patients: Forty-nine bony nonunion cases undergoing revision internal fixation and 45 healed fracture controls undergoing removal of hardware. Intervention: Bacterial infection was detected by standard microbial culture methods and by a pan-eubacterial domain, molecular diagnostic (MDx) assay. Confirmation of culture and MDx results was achieved with bacterial ribosomal 16S rRNA fluorescence in situ hybridization (FISH) to visualize bacterial biofilms. Main Outcome Measurements: MDx and microbial culture methods results were the primary study outcomes. Results: Ninety-four percent of the nonunion cohort and 93% of the union cohort had bacteria detected by the MDx. Seventy-eight percent of the nonunion cases and 69% of the controls were culture negative, but MDx positive. Although no significant differences in bacterial composition were observed between the cases and controls, differences were observed when cases were divided by comorbidities. Conclusion: The MDx is more sensitive than microbial culture in detecting bacterial presence. The lack of significantly different findings with regard to bacterial profile identified between the cases and controls suggests that host factors and environmental conditions are largely responsible for determining if bony union will occur. Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Daniel T Altman
- Department of Orthopedics, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Gregory T Altman
- Department of Orthopedics, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Jeffrey J Sewecke
- Department of Orthopedics, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Courtney Saltarski
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Laura Nistico
- Center of Excellence in Biofilm Research Genomic Sciences, Allegheny Singer Research Institute, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Rachael Melton-Kreft
- Center of Excellence in Biofilm Research Genomic Sciences, Allegheny Singer Research Institute, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Fen Z Hu
- Center for Biofilms and Surgical Infections, Center for Genomic Sciences, and Center for Advanced Microbial Processing, Institute of Molecular Medicine and Infectious Disease, Philadelphia, Pennsylvania, USA.,Departments of Microbiology and Immunology, and Otolaryngology Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Garth D Ehrlich
- Center for Biofilms and Surgical Infections, Center for Genomic Sciences, and Center for Advanced Microbial Processing, Institute of Molecular Medicine and Infectious Disease, Philadelphia, Pennsylvania, USA.,Departments of Microbiology and Immunology, and Otolaryngology Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
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28
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Hsu JE, Harrison D, Anderson K, Huang C, Whitson AJ, Matsen FA, Bumgarner RE. Cutibacterium recovered from deep specimens at the time of revision shoulder arthroplasty samples has increased biofilm-forming capacity and hemolytic activity compared with Cutibacterium skin isolates from normal subjects. J Shoulder Elbow Surg 2022; 31:318-323. [PMID: 34411722 DOI: 10.1016/j.jse.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 07/01/2021] [Accepted: 07/11/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Biofilm formation and hemolytic activity are factors that may correlate with the virulence of Cutibacterium. We sought to compare the prevalence of these potential markers of pathogenicity between Cutibacterium recovered from deep specimens obtained at the time of surgical revision for failed shoulder arthroplasty and Cutibacterium recovered from skin samples from normal subjects. METHODS We compared 42 deep-tissue or explant isolates with 43 control Cutibacterium samples obtained from skin isolates from normal subjects. Subtyping information was available for all isolates. Biofilm-forming capacity was measured by inoculating a normalized amount of each isolate onto a 96-well plate. Planktonic bacteria were removed, the remaining adherent bacteria were stained with crystal violet, the crystal violet was re-solubilized in ethyl alcohol, and biofilm-forming capacity was quantitated by optical density (OD). Hemolytic activity was measured by plating a normalized amount of isolate onto agar plates. The area of the colony and the surrounding area of blood lysis were measured and reported as minimal, moderate, or severe hemolysis. RESULTS Biofilm-forming capacity was significantly higher in the tissue and explant samples compared with the control skin samples (OD of 0.34 ± 0.30 for deep tissue vs. 0.20 ± 0.28 for skin, P = .002). Hemolytic activity was also significantly higher in the tissue and explant samples than in the control skin samples (P < .0001). Samples with hemolytic activity had significantly higher biofilm-forming capacity compared with samples without hemolytic activity (OD of 0.27 ± 0.29 vs. 0.12 ± 0.15, P = .015). No difference in biofilm-forming capacity or hemolytic activity was found between subtypes. CONCLUSIONS Cutibacterium obtained from deep specimens at the time of revision shoulder arthroplasty has higher biofilm-forming capacity and hemolytic activity than Cutibacterium recovered from the skin of normal subjects. These data add support for the view that Cutibacterium harvested from deep tissues may have clinically significant virulence characteristics. The lack of correlation between these clinically relevant phenotypes and subtypes indicates that additional study is needed to identify genotypic markers that better correlate with biofilm and hemolytic activity.
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Affiliation(s)
- Jason E Hsu
- Department of Orthopaedics, University of Washington, Seattle, WA, USA
| | - Della Harrison
- Department of Microbiology, University of Washington, Seattle, WA, USA
| | - Kelvin Anderson
- Department of Microbiology, University of Washington, Seattle, WA, USA
| | - Christopher Huang
- Department of Microbiology, University of Washington, Seattle, WA, USA
| | | | | | - Roger E Bumgarner
- Department of Microbiology, University of Washington, Seattle, WA, USA.
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29
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Factors associated with failure of surgical revision and IV antibiotics to resolve Cutibacterium periprosthetic infection of the shoulder. INTERNATIONAL ORTHOPAEDICS 2022; 46:555-562. [PMID: 35031818 DOI: 10.1007/s00264-021-05259-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 10/30/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Cutibacterium is the most common organism causing shoulder periprosthetic infection (PJI). While most shoulder PJIs are well treated by prosthesis exchange and antibiotics, in some cases this treatment fails to resolve the infection. The factors associated with these failures have not been previously identified. The aim of this study was to identify the characteristics of patients with failure of treatment for PJI. METHODS Thirty-five patients suspected of having Cutibacterium PJI had revision arthroplasty with single-stage implant exchange followed by intravenous antibiotics. The characteristics of those with ≥ two positive cultures at revision surgery were compared to those who did not. The characteristics of those patients having a re-revision with ≥ two positive deep cultures (documented treatment failures) were compared to those who did not. RESULTS The 17 patients that had ≥ two positive cultures at their index revision were more likely to be male, to have had ream and run procedures, and to have higher loads of Cutibacterium on pre-operative cultures of their unprepared skin. The five patients that had documented treatment failure had higher loads of Cutibacterium on their skin and in deep cultures obtained at their index revision. CONCLUSION Patients harboring high loads of Cutibacterium on their unprepared skin prior to revision and high loads of Cutibacterium on deep cultures at the time of their index revision are at increased risk for failure of implant exchange and antibiotics to resolve a Cutibacterium PJI.
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30
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van Sloten M, Gómez-Junyent J, Ferry T, Rossi N, Petersdorf S, Lange J, Corona P, Araújo Abreu M, Borens O, Zlatian O, Soundarrajan D, Rajasekaran S, Wouthuyzen-Bakker M. Should all patients with a culture-negative periprosthetic joint infection be treated with antibiotics? : a multicentre observational study. Bone Joint J 2022; 104-B:183-188. [PMID: 34969292 DOI: 10.1302/0301-620x.104b1.bjj-2021-0693.r2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to analyze the prevalence of culture-negative periprosthetic joint infections (PJIs) when adequate methods of culture are used, and to evaluate the outcome in patients who were treated with antibiotics for a culture-negative PJI compared with those in whom antibiotics were withheld. METHODS A multicentre observational study was undertaken: 1,553 acute and 1,556 chronic PJIs, diagnosed between 2013 and 2018, were retrospectively analyzed. Culture-negative PJIs were diagnosed according to the Muskuloskeletal Infection Society (MSIS), International Consensus Meeting (ICM), and European Bone and Joint Society (EBJIS) definitions. The primary outcome was recurrent infection, and the secondary outcome was removal of the prosthetic components for any indication, both during a follow-up period of two years. RESULTS None of the acute PJIs and 70 of the chronic PJIs (4.7%) were culture-negative; a total of 36 culture-negative PJIs (51%) were treated with antibiotics, particularly those with histological signs of infection. After two years of follow-up, no recurrent infections occurred in patients in whom antibiotics were withheld. The requirement for removal of the components for any indication during follow-up was not significantly different in those who received antibiotics compared with those in whom antibiotics were withheld (7.1% vs 2.9%; p = 0.431). CONCLUSION When adequate methods of culture are used, the incidence of culture-negative PJIs is low. In patients with culture-negative PJI, antibiotic treatment can probably be withheld if there are no histological signs of infection. In all other patients, diagnostic efforts should be made to identify the causative microorganism by means of serology or molecular techniques. Cite this article: Bone Joint J 2022;104-B(1):183-188.
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Affiliation(s)
- Maxime van Sloten
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Joan Gómez-Junyent
- Department of Infectious Diseases, Hospital del Mar, Infectious Pathology and Antimicrobial Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona (UAB), CEXS-Universitat Pompeu Fabra, Barcelona, Spain
| | - Tristan Ferry
- Department of Infectious and Tropical Diseases, Hospital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Nicolò Rossi
- Infectious Diseases Unit, University Hospital IRCCS Policlinico Sant'Orsola, Bologna, Italy
| | - Sabine Petersdorf
- Institute of Medical Laboratory Diagnostics, HELIOS University Clinic Wuppertal, Witten/Herdecke University, Witten, Germany
| | - Jeppe Lange
- H-HiP, Department of Orthopaedic Surgery, Regional Hospital Horsens, Horsens, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Pablo Corona
- Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Miguel Araújo Abreu
- Department of Infectious Diseases, Centro Hospitalar e Universitário do Porto. GRIP, Porto Bone & Joint infection group, Porto, Portugal
| | - Olivier Borens
- Department of Orthopaedics and Traumatology, Septic surgical Unit, University Hospital of Lausanne, CHUV, University of Lausanne, Lausanne, Switzerland
| | - Ovidiu Zlatian
- Department of Microbiology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | | | - S Rajasekaran
- Department of Orthopaedics, Ganga Hospital, Coimbatore, India
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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31
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Schiffman CJ, Hsu JE, Khoo KJ, Whitson A, Yao JJ, Wu JC, Matsen FA. Association Between Serum Testosterone Levels and Cutibacterium Skin Load in Patients Undergoing Elective Shoulder Arthroplasty: A Cohort Study. JB JS Open Access 2021; 6:JBJSOA-D-21-00030. [PMID: 34901690 PMCID: PMC8654446 DOI: 10.2106/jbjs.oa.21.00030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Cutibacterium periprosthetic joint infections are important complications of shoulder arthroplasty. Although it is known that these infections are more common among men and that they are more common in patients with high levels of Cutibacterium on the skin, the possible relationship between serum testosterone levels and skin Cutibacterium levels has not been investigated.
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Affiliation(s)
- Corey J Schiffman
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
| | - Jason E Hsu
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
| | - Kevin J Khoo
- University of Washington School of Medicine, Seattle, Washington
| | - Anastasia Whitson
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
| | - Jie J Yao
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
| | - John C Wu
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
| | - Frederick A Matsen
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
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Oliva A, Miele MC, Al Ismail D, Di Timoteo F, De Angelis M, Rosa L, Cutone A, Venditti M, Mascellino MT, Valenti P, Mastroianni CM. Challenges in the Microbiological Diagnosis of Implant-Associated Infections: A Summary of the Current Knowledge. Front Microbiol 2021; 12:750460. [PMID: 34777301 PMCID: PMC8586543 DOI: 10.3389/fmicb.2021.750460] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/04/2021] [Indexed: 12/14/2022] Open
Abstract
Implant-associated infections are characterized by microbial biofilm formation on implant surface, which renders the microbiological diagnosis challenging and requires, in the majority of cases, a complete device removal along with a prolonged antimicrobial therapy. Traditional cultures have shown unsatisfactory sensitivity and a significant advance in the field has been represented by both the application of the sonication technique for the detachment of live bacteria from biofilm and the implementation of metabolic and molecular assays. However, despite the recent progresses in the microbiological diagnosis have considerably reduced the rate of culture-negative infections, still their reported incidence is not negligible. Overall, several culture- and non-culture based methods have been developed for diagnosis optimization, which mostly relies on pre-operative and intra-operative (i.e., removed implants and surrounding tissues) samples. This review outlines the principal culture- and non-culture based methods for the diagnosis of the causative agents of implant-associated infections and gives an overview on their application in the clinical practice. Furthermore, advantages and disadvantages of each method are described.
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Affiliation(s)
- Alessandra Oliva
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Maria Claudia Miele
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Dania Al Ismail
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Federica Di Timoteo
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Massimiliano De Angelis
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Luigi Rosa
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Antimo Cutone
- Department of Biosciences and Territory, University of Molise, Pesche, Italy
| | - Mario Venditti
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Maria Teresa Mascellino
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Piera Valenti
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
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El Sayed F, Jeverica S, Roux AL, Bauer T, Nkam L, Sivadon-Tardy V, Noussair L, Herrmann JL, Gaillard JL, Rak M, Papst L, Rottman M. Cutibacterium acnes clonal complexes display various growth rates in blood culture vials used for diagnosing orthopedic device-related infections. Anaerobe 2021; 72:102469. [PMID: 34699978 DOI: 10.1016/j.anaerobe.2021.102469] [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: 06/29/2021] [Revised: 09/17/2021] [Accepted: 10/20/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Blood culture bottles (BCBs) are commonly used for the diagnosis of infections associated with orthopedic devices. Although Cutibacterium acnes is an important pathogen in orthopedics, relatively little is known about its growth characteristics in BCBs. This prompted us to analyze the influence of bacterial genotype and clinical significance on time-to-detection (TTD) in BCBs. METHODS We reviewed 59 cases of orthopedic device-related infections in which at least one intraoperative specimen yielded a pure C. acnes culture from anaerobic BCBs (BD Bactec Lytic/10 Anaerobic/F; Lytic-Ana) and/or solid media. A strain was considered infectant if the same genotype was present in two or more intraoperative samples. From these cases, we isolated a total of 72 unique C. acnes strains belonging to four multilocus sequence type clonal complexes (CCs): CC18, CC28, CC36 and CC53. Growth rate and TTD in Lytic-Ana BCB were studied under experimental conditions (inoculation of standard inoculum) and in clinical samples (inoculation of periprosthetic tissue samples). RESULTS Median TTD values were shorter for CC53 compared to other CCs under experimental conditions (69 vs. 103 h; p < 0.001) and from clinical specimens (70 vs. 200 h; p = 0.02). Infectant strains had a shorter median TTD compared to contaminant strains in a clinical situation, while the difference was not observed under experimental conditions. CONCLUSIONS The detection dynamics of C. acnes in Lytic-Ana BCBs were associated with genotype. Thus, TTD not only reflects the bacterial load in clinical samples, but may also reflect the intrinsic properties of the clonal complex of C. acnes.
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Affiliation(s)
- Faten El Sayed
- APHP, GHU Paris Saclay, Hôpital Ambroise Paré, Microbiology Department, Boulogne-Billancourt, France; Université Paris-Saclay, UVSQ, Inserm, Infection et Inflammation, Montigny-Le-Bretonneux, France.
| | - Samo Jeverica
- National Laboratory of Health, Environment and Food, Maribor, Slovenia
| | - Anne-Laure Roux
- APHP, GHU Paris Saclay, Hôpital Ambroise Paré, Microbiology Department, Boulogne-Billancourt, France; Université Paris-Saclay, UVSQ, Inserm, Infection et Inflammation, Montigny-Le-Bretonneux, France
| | - Thomas Bauer
- APHP, GHU Paris Saclay, Hôpital Ambroise Paré, Orthopedic Surgery Department, Boulogne-Billancourt, France
| | - Lionelle Nkam
- Clinical Research Unit, APHP Paris Saclay Ouest, Ambroise Paré Hospital, Boulogne-Billancourt, France
| | - Valérie Sivadon-Tardy
- APHP, GHU Paris Saclay, Hôpital Ambroise Paré, Microbiology Department, Boulogne-Billancourt, France
| | - Latifa Noussair
- APHP, GHU Paris Saclay, Hôpital Raymond Poincaré, Microbiology Department, Garches, France
| | - Jean-Louis Herrmann
- Université Paris-Saclay, UVSQ, Inserm, Infection et Inflammation, Montigny-Le-Bretonneux, France; APHP, GHU Paris Saclay, Hôpital Raymond Poincaré, Microbiology Department, Garches, France
| | - Jean-Louis Gaillard
- APHP, GHU Paris Saclay, Hôpital Ambroise Paré, Microbiology Department, Boulogne-Billancourt, France; Université Paris-Saclay, UVSQ, Inserm, Infection et Inflammation, Montigny-Le-Bretonneux, France
| | - Mitja Rak
- National Laboratory of Health, Environment and Food, Maribor, Slovenia
| | - Lea Papst
- Department of Infectious Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Martin Rottman
- Université Paris-Saclay, UVSQ, Inserm, Infection et Inflammation, Montigny-Le-Bretonneux, France; APHP, GHU Paris Saclay, Hôpital Raymond Poincaré, Microbiology Department, Garches, France
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Ponraj D, Falstie-Jensen T, Jørgensen N, Ravn C, Brüggemann H, Lange J. Diagnosis of orthopaedic-implant-associated infections caused by slow-growing Gram-positive anaerobic bacteria - a clinical perspective. J Bone Jt Infect 2021; 6:367-378. [PMID: 34660180 PMCID: PMC8515996 DOI: 10.5194/jbji-6-367-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 09/13/2021] [Indexed: 12/21/2022] Open
Abstract
Slow-growing Gram-positive anaerobic bacteria (SGAB) such as Cutibacterium acnes are increasingly recognized as causative agents of implant-associated infections (IAIs) in orthopaedic surgeries. SGAB IAIs are difficult to diagnose because of their non-specific clinical and laboratory findings as well as the fastidious growth conditions required by these bacteria. A high degree of clinical suspicion and awareness of the various available diagnostic methods is therefore important. This review gives an overview of the current knowledge regarding SGAB IAI, providing details about clinical features and available diagnostic methodologies. In recent years, new methods for the diagnosis of IAI were developed, but there is limited knowledge about their usefulness in SGAB IAI. Further studies are required to determine the ideal diagnostic methodology to identify these infections so that they are not overlooked and mistakenly classified as aseptic failure.
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Affiliation(s)
| | - Thomas Falstie-Jensen
- Department of Orthopaedic Surgery, Aarhus University Hospital,
Aarhus, 8200, Denmark
| | | | - Christen Ravn
- Department of Orthopaedic Surgery, Lillebaelt Hospital, Kolding,
6000, Denmark
| | | | - Jeppe Lange
- Department of Clinical Medicine, Aarhus University, Aarhus, 8000,
Denmark
- Department of Orthopaedic Surgery, Horsens Regional Hospital,
Horsens, 8700, Denmark
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Gupta V, Kaur M, Bora P, Kumari P, Datta P, Gupta R, Chander J. A Prospective Study to Assess the Optimal Incubation Times for Culture and Aerobic Bacterial Profile in Prosthetic Joint Infections. J Lab Physicians 2021; 13:224-230. [PMID: 34602786 PMCID: PMC8478509 DOI: 10.1055/s-0041-1730879] [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: 11/29/2022] Open
Abstract
Introduction
With an increase in the number of total joint arthroplasties, the count of prosthetic joint infections (PJIs) is also increasing and has become a nightmare for an orthopaedic surgeon. Microbiological diagnosis is important for administering definitive antimicrobial treatment. Negative culture reports hamper patient management and prolonged incubation periods have increased the culture yield but at the risk of culture contamination in conventional microbiology settings. Thus, we aimed to optimize the best incubation time for culture and the aerobic bacterial profile of PJIs.
Material and Methods
Over a year, samples from clinically suspected PJI patients were collected and processed for culture using standard techniques. The samples were incubated for up to 10 days with daily subculturing on to solid media. The bacterial isolates were identified and antibiotic susceptibility was performed.
Results
Out of 200 patients, 105 were included in the study and samples were collected in triplicate. In 70 cases culture was positive and 35 were culture negative PJIs. Mean incubation days to culture positivity was 3.6 days with 97.14% culture positivity seen by the seventh day of incubation. Twenty-four percent
methicillin-resistant Staphylococcus aureus
, and more than 50% extended spectrum β lactamase producing
Klebsiella pneumoniae
and
Escherichia coli
were isolated.
Discussion
Culture positivity in PJIs provides definitive evidence of infection and guides the treatment. Increasing the incubation times can help in maximizing the culture yield, and we found that 97.14% pathogens grew within 7 days of incubation. Prolonging it further would not provide an added advantage especially in a resource-constraint setting.
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Affiliation(s)
- Varsha Gupta
- Department of Microbiology, Government Medical College Hospital, Chandigarh, Punjab, India
| | - Mandeep Kaur
- Department of Microbiology, Adesh Institute of Medical Sciences and Research, Bathinda, Punjab, India
| | - Prapti Bora
- Department of Microbiology, Government Medical College Hospital, Chandigarh, Punjab, India
| | - Pooja Kumari
- Department of Microbiology, Government Medical College Hospital, Chandigarh, Punjab, India
| | - Priya Datta
- Department of Medical Parasitology, Postgraduate Institute of Medical Education and Research, Chandigarh, Punjab, India
| | - Ravi Gupta
- Department of Orthopedics, Government Medical College Hospital, Chandigarh, Punjab, India
| | - Jagdish Chander
- Department of Microbiology, Government Medical College Hospital, Chandigarh, Punjab, India
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Contreras ES, Deiparine S, Ulrich MN, Alvarez PM, Bishop JY, Cvetanovich GL. The utility and cost of atypical cultures in revision shoulder arthroplasty. J Shoulder Elbow Surg 2021; 30:2325-2330. [PMID: 33711497 DOI: 10.1016/j.jse.2021.02.016] [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: 11/17/2020] [Revised: 02/11/2021] [Accepted: 02/13/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND At the time of revision shoulder arthroplasty, it is common practice to take cultures to evaluate for prosthetic joint infection even when an alternative cause of failure has been identified. Although isolation of fungal or acid-fast organisms is rare, it remains common practice to send all specimens for aerobic, anaerobic, and atypical (fungal and acid-fast) cultures. We hypothesize that the rate of positive atypical cultures at the time of revision shoulder arthroplasty is very low and routine use imposes a considerable financial burden on the health care system. METHODS A retrospective review of all revision shoulder arthroplasties performed between January 1, 2010, and December 31, 2019, at our institution was performed. Patients with a hemiarthroplasty, total shoulder arthroplasty, reverse shoulder arthroplasty, or pre-existing antibiotic spacer who underwent revision to hemiarthroplasty, total shoulder arthroplasty, reverse shoulder arthroplasty, antibiotic spacer, or resection arthroplasty were included. Electronic patient charts were reviewed to gather patient, surgical, and culture data. An analysis of the hospital billing charges associated with each culture was performed using our hospital billing database and the current procedural terminology (CPT) codes for aerobic, anaerobic, fungal, and acid-fast cultures. A secondary outcome analysis was performed to identify factors associated with positive cultures. RESULTS A total of 237 revision shoulder arthroplasties performed on 189 patients were analyzed. Cultures were sent on 158 of 237 (66.7%) surgeries with an average of 2.2 specimens per surgery. A total of 341 aerobic, 331 anaerobic, 187 fungal, and 174 acid-fast cultures were collected. Positive cultures were found in 52 of 341 (15.2%) aerobic cultures and 36 of 331 (10.9%) anaerobic cultures. The most commonly isolated organism was Cutibacterium acnes (42.2%), followed by methicillin-resistant Staphylococcus aureus (15.6%), coagulase-negative Staphylococcus species (13.3%), and methicillin-sensitive S. aureus (12.2%). There were zero positive fungal or acid-fast cultures in our series. The total billing charges for aerobic, anaerobic, fungal, and acid-fast cultures over the study period were $77,748, $23,832, $8,789, and $106,662, respectively, with atypical cultures accounting for 53.2% of the total charges for all cultures. For a single sample sent for all 4 culture types, atypical cultures account for 69% of the total amount charged. CONCLUSION Isolation of fungal or acid-fast organisms at the time of revision shoulder arthroplasty is rare and imposes a considerable financial burden when these atypical cultures are sent on a routine basis. The collection of fungal and acid-fast cultures should be reserved for patients in whom risk factors for these atypical organisms have been identified.
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Affiliation(s)
- Erik S Contreras
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Selina Deiparine
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Marisa N Ulrich
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Paul M Alvarez
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Julie Y Bishop
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Gregory L Cvetanovich
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Sigmund IK, McNally MA, Luger M, Böhler C, Windhager R, Sulzbacher I. Diagnostic accuracy of neutrophil counts in histopathological tissue analysis in periprosthetic joint infection using the ICM, IDSA, and EBJIS criteria. Bone Joint Res 2021; 10:536-547. [PMID: 34409845 PMCID: PMC8414440 DOI: 10.1302/2046-3758.108.bjr-2021-0058.r1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Aims Histology is an established tool in diagnosing periprosthetic joint infections (PJIs). Different thresholds, using various infection definitions and histopathological criteria, have been described. This study determined the performance of different thresholds of polymorphonuclear neutrophils (≥ 5 PMN/HPF, ≥ 10 PMN/HPF, ≥ 23 PMN/10 HPF) , when using the European Bone and Joint Infection Society (EBJIS), Infectious Diseases Society of America (IDSA), and the International Consensus Meeting (ICM) 2018 criteria for PJI. Methods A total of 119 patients undergoing revision total hip (rTHA) or knee arthroplasty (rTKA) were included. Permanent histology sections of periprosthetic tissue were evaluated under high power (400× magnification) and neutrophils were counted per HPF. The mean neutrophil count in ten HPFs was calculated (PMN/HPF). Based on receiver operating characteristic (ROC) curve analysis and the z-test, thresholds were compared. Results Using the EBJIS criteria, a cut-off of ≥ five PMN/HPF showed a sensitivity of 93% (95% confidence interval (CI) 81 to 98) and specificity of 84% (95% CI 74 to 91). The optimal threshold when applying the IDSA and ICM criteria was ≥ ten PMN/HPF with sensitivities of 94% (95% CI 79 to 99) and 90% (95% CI 76 to 97), and specificities of 86% (95% CI 77 to 92) and 92% (95% CI 84 to 97), respectively. In rTKA, a better performance of histopathological analysis was observed in comparison with rTHA when using the IDSA criteria (p < 0.001). Conclusion With high accuracy, histopathological analysis can be supported as a confirmatory criterion in diagnosing periprosthetic joint infections. A threshold of ≥ five PMN/HPF can be recommended to distinguish between septic and aseptic loosening, with an increased possibility of detecting more infections caused by low-virulence organisms. However, neutrophil counts between one and five should be considered suggestive of infection and interpreted carefully in conjunction with other diagnostic test methods. Cite this article: Bone Joint Res 2021;10(8):536–547.
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Affiliation(s)
- Irene K Sigmund
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Markus Luger
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Christoph Böhler
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Reinhard Windhager
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Irene Sulzbacher
- Department of Pathology, Medical University of Vienna, Vienna, Austria
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Neufeld ME, Lanting BA, Shehata M, Howard JL, MacDonald SJ, Teeter MG, Vasarhelyi EM. Prevalence and Outcomes of Unexpected Positive Intraoperative Cultures in Presumed Aseptic Revision Hip Arthroplasty. J Bone Joint Surg Am 2021; 103:1392-1401. [PMID: 33974575 DOI: 10.2106/jbjs.20.01559] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The prevalence and outcomes of unexpected positive cultures (UPCs) of specimens taken during presumed aseptic revision total hip arthroplasty (THA) are unclear. The purpose of this study was to determine the prevalence of UPC and infection-free implant survival in this patient population. Secondary aims included identifying factors associated with subsequent infection-related failure in patients with UPC. METHODS We reviewed all THA revisions (n = 2,288) performed at our institution from 2006 to 2019. Presumed aseptic revision THAs with intraoperative culture(s) were eligible (n = 1,196), and those with UPC were included in a Kaplan-Meier analysis to determine the infection-free implant survival and in Cox regression analysis to identify factors associated with infection-related failure. RESULTS UPC(s) were documented for 9.2% (110) of 1,196 aseptic THA revisions. The 2- and 5-year infection-free implant survival in the entire UPC cohort was 93.1% (95% confidence interval [CI] = 90.5% to 95.7%) and 86.8% (95% CI = 82.9% to 90.7%), respectively. The 2- and 5-year infection-free survival with failure due to infection with the same microorganism as identified in the UPC as the end point was 95.8% (95% CI = 93.7% to 97.9%) and 94.3% (95% CI = 91.7% to 96.9%), respectively. Subsequent infection-related failures caused by the same microorganism as identified in the UPC were more likely to occur after revisions with ≥2 UPCs than after those with 1 UPC (p = 0.024). Revision due to adverse metal reaction was a risk factor for subsequent infection-related failure (hazard ratio [HR] = 14.49, 95% CI = 2.69 to 78.04). Patients with a single UPC who were not treated with antibiotics had no subsequent periprosthetic joint infections (PJIs) caused by the same microorganism as identified in the UPC. CONCLUSIONS The prevalence of UPC was 9.2%, and the infection-free implant survival in patients with UPC is encouraging. Implant survival free of PJI caused by the same microorganism as identified in the UPC was excellent. Aseptic revision for adverse metal reaction was a risk factor for subsequent PJI in patients with UPC. No patient with a single UPC who was not treated with antibiotics developed PJI caused by the UPC-identified microorganism, suggesting that in the absence of other signs of infection a single UPC does not warrant antibiotic treatment. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Michael E Neufeld
- Division of Orthopaedic Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University and London Health Science Centre, London, Ontario, Canada
| | - Brent A Lanting
- Division of Orthopaedic Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University and London Health Science Centre, London, Ontario, Canada.,Bone and Joint Institute, Western University, London, Ontario, Canada
| | - Michael Shehata
- Division of Orthopaedic Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University and London Health Science Centre, London, Ontario, Canada
| | - James L Howard
- Division of Orthopaedic Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University and London Health Science Centre, London, Ontario, Canada.,Bone and Joint Institute, Western University, London, Ontario, Canada
| | - Steven J MacDonald
- Division of Orthopaedic Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University and London Health Science Centre, London, Ontario, Canada.,Bone and Joint Institute, Western University, London, Ontario, Canada
| | - Matthew G Teeter
- Division of Orthopaedic Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University and London Health Science Centre, London, Ontario, Canada.,Bone and Joint Institute, Western University, London, Ontario, Canada.,Department of Medical Biophysics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Edward M Vasarhelyi
- Division of Orthopaedic Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University and London Health Science Centre, London, Ontario, Canada.,Bone and Joint Institute, Western University, London, Ontario, Canada
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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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Salar-Vidal L, Martin-Garcia M, Auñón A, Esteban J. Cutibacterium spp. isolated from orthopaedic implant-associated infection: A not-so-slowly growing organism. ACTA ACUST UNITED AC 2021; 39:287-290. [PMID: 34088450 DOI: 10.1016/j.eimce.2020.05.017] [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: 03/02/2020] [Accepted: 05/25/2020] [Indexed: 10/21/2022]
Abstract
INTRODUCTION It has been reported that microbiological diagnosis of Cutibacterium spp. infection requires a prolonged incubation time (up to 14 days). We present our experience with regard to incubation time for detection of Cutibacterium spp. in orthopaedic samples over a 10-year period. METHODS One hundred and nineteen samples were included in this retrospective study. Fifty-three were implants (having previously undergone sonication), 64 were periprosthetic tissue biopsies and two were synovial fluids. Atkins's criteria were used for interpreting the isolates. Quantification and number of days until a culture became positive for Cutibacterium spp. were evaluated. RESULTS The median number of days to detection of a clinically significant isolate and a contaminant was 4 days. No clinically significant isolates grew after day eight. CONCLUSION Most clinically significant isolates of Cutibacterium spp. are detected in the first 7 days of incubation, although a recommendation of prolonged incubation (up to 14 days) appears to be necessary for detecting other organisms.
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Affiliation(s)
- Llanos Salar-Vidal
- Departments of Clinical Microbiology and *Orthopaedic Surgery, IIS-Fundación Jiménez Díaz, UAM, Madrid, Spain
| | - Marta Martin-Garcia
- Departments of Clinical Microbiology and *Orthopaedic Surgery, IIS-Fundación Jiménez Díaz, UAM, Madrid, Spain
| | - Alvaro Auñón
- Departments of Clinical Microbiology and *Orthopaedic Surgery, IIS-Fundación Jiménez Díaz, UAM, Madrid, Spain
| | - Jaime Esteban
- Departments of Clinical Microbiology and *Orthopaedic Surgery, IIS-Fundación Jiménez Díaz, UAM, Madrid, Spain.
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Kardile MP, Bains SS, Kuo CC, Lincoln TL, Bains RS. Is Propionibacterium acnes becoming the most common bacteria in delayed infections following adolescent idiopathic scoliosis surgery? Spine Deform 2021; 9:757-767. [PMID: 33555598 DOI: 10.1007/s43390-020-00250-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 11/03/2020] [Indexed: 12/20/2022]
Abstract
STUDY DESIGN Retrospective review of hospital charts. OBJECTIVE (1) To determine the microbiological profile of patients with surgical site infections following posterior spinal fusion surgery (PSF) for Adolescent Idiopathic scoliosis (AIS). (2) To study the treatment outcome of patients with surgical site infections (SSI) following surgery for AIS. (3) To identify the key differences in presentation and management of acute and delayed SSI following AIS surgery. There has been increasing evidence of the role of P. acnes in deep surgical site infections. Literature related to this is abundant in relation to shoulder arthroplasty; however, it is sparse in relation to spine surgery. METHODS We conducted a retrospective review of all patients treated for AIS during a 5-year period (2010-2014) at our institution, with a minimum of 2-year follow-up after the index surgery. Patients with a postoperative infection following their index surgery were included. Charts of AIS patients with post-op infections were reviewed for details of the index surgery, time to presentation of the infection, presenting signs/symptoms, microbiology details, details of surgical and antibiotic treatment, and outcomes. RESULTS Nine (2.8%) post-op infections were identified out of 315 cases for AIS during this period. Seven (2.2%) involved P. acnes. Two (0.6%) involved MSSA. The average time for cultures to show growth was 6.1 days (range 5-8 days) in P. acnes group and 2-3 days in MSSA group. Patients with P. acnes infections were treated with implant removal, debridement and antibiotics. All patients achieved solid fusion except two patients from the P. acnes group had pseudoarthrosis and had to undergo revision fusion. CONCLUSION Propionibacterium acnes was the single most common bacteria isolated from delayed surgical site infection following PSF in AIS patients. Optimal treatment consists of debridement, implant removal and antibiotics. These patients have high incidence of pseudoarthrosis. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Mayur P Kardile
- Northern California Regional Spine Center, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Suite 15, Oakland, CA, 94611, USA
| | - Sukhraj S Bains
- USC, Keck School of Medicine, 1975 Zonal Ave, Los Angeles, CA, USA
| | - Calvin C Kuo
- Northern California Regional Spine Center, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Suite 15, Oakland, CA, 94611, USA
| | - Todd L Lincoln
- Northern California Regional Spine Center, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Suite 15, Oakland, CA, 94611, USA
| | - Ravi S Bains
- Northern California Regional Spine Center, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Suite 15, Oakland, CA, 94611, USA.
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Vilchez HH, Escudero-Sanchez R, Fernandez-Sampedro M, Murillo O, Auñón Á, Rodríguez-Pardo D, Jover-Sáenz A, del Toro MD, Rico A, Falgueras L, Praena-Segovia J, Guío L, Iribarren JA, Lora-Tamayo J, Benito N, Morata L, Ramirez A, Riera M. Prosthetic Shoulder Joint Infection by Cutibacterium acnes: Does Rifampin Improve Prognosis? A Retrospective, Multicenter, Observational Study. Antibiotics (Basel) 2021; 10:antibiotics10050475. [PMID: 33919103 PMCID: PMC8143127 DOI: 10.3390/antibiotics10050475] [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: 03/28/2021] [Revised: 04/13/2021] [Accepted: 04/19/2021] [Indexed: 02/07/2023] Open
Abstract
This retrospective, multicenter observational study aimed to describe the outcomes of surgical and medical treatment of C. acnes-related prosthetic joint infection (PJI) and the potential benefit of rifampin-based therapies. Patients with C. acnes-related PJI who were diagnosed and treated between January 2003 and December 2016 were included. We analyzed 44 patients with C. acnes-related PJI (median age, 67.5 years (IQR, 57.3-75.8)); 75% were men. The majority (61.4%) had late chronic infection according to the Tsukayama classification. All patients received surgical treatment, and most antibiotic regimens (43.2%) included β-lactam. Thirty-four patients (87.17%) were cured; five showed relapse. The final outcome (cure vs. relapse) showed a nonsignificant trend toward higher failure frequency among patients with previous prosthesis (OR: 6.89; 95% CI: 0.80-58.90) or prior surgery and infection (OR: 10.67; 95% IC: 1.08-105.28) in the same joint. Patients treated with clindamycin alone had a higher recurrence rate (40.0% vs. 8.8%). Rifampin treatment did not decrease recurrence in patients treated with β-lactams. Prior prosthesis, surgery, or infection in the same joint might be related to recurrence, and rifampin-based combinations do not seem to improve prognosis. Debridement and implant retention appear a safe option for surgical treatment of early PJI.
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Affiliation(s)
- Helem H. Vilchez
- Infectious Diseases Unit, Internal Medicine Department, Hospital Universitari Son Espases, Fundació Institut d’Investigació Sanitària Illes Balears (IdISBa), 07120 Palma de Mallorca, Spain;
- Correspondence: ; Tel.: +34-653419331
| | - Rosa Escudero-Sanchez
- Infectious Diseases Department, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain;
| | - Marta Fernandez-Sampedro
- Infectious Diseases Unit, Department of Medicine, Hospital Universitario Marqués de Valdecilla-IDIVAL, 39008 Cantabria, Spain;
| | - Oscar Murillo
- Infectious Diseases Department, Hospital Universitari de Bellvitge, 08907 Barcelona, Spain;
| | - Álvaro Auñón
- Bone and Joint Infection Unit, Department of Orthopaedic Surgery, IIS-Fundación Jiménez Díaz, 28040 Madrid, Spain;
| | - Dolors Rodríguez-Pardo
- Infectious Diseases Department, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain;
| | - Alfredo Jover-Sáenz
- Unit of Nosocomial Infection, Hospital Universitari Arnau de Vilanova, 25198 Lleida, Spain;
| | - Mª Dolores del Toro
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Hospital Universitario Virgen Macarena CSIC, Instituto de Biomedicina de Sevilla (IBiS), Universidad de Sevilla, 41009 Sevilla, Spain;
| | - Alicia Rico
- Infectious Diseases Unit and Clinical Microbiology, Hospital Universitario La Paz, 28046 Madrid, Spain;
| | - Luis Falgueras
- Infectious Diseases Department, Corporació Sanitària Parc Taulí, 08208 Barcelona, Spain;
| | - Julia Praena-Segovia
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, University Hospital Virgen del Rocio, 41013 Sevilla, Spain;
| | - Laura Guío
- Infectious Diseases Department, Hospital Universitario Cruces, 48903 Vizcaya, Spain;
| | - José A. Iribarren
- Infectious Diseases Department, Hospital Universitario Donostia, Instituto BioDonostia, 20014 San Sebastián, Spain;
| | - Jaime Lora-Tamayo
- Infectious Diseases Unit, Internal Medicine Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre “i + 12”, 28041 Madrid, Spain;
| | - Natividad Benito
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau-Institut d’Investigació Biomèdica Sant Pau, Departament of Medicine, Universitat Autònoma de Barcelona, 08041 Barcelona, Spain;
| | - Laura Morata
- Department of Infectious Diseases, Hospital Clínic of Barcelona, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain;
| | - Antonio Ramirez
- Microbiologic Department, Hospital Universitari Son Espases, 07120 Palma de Mallorca, Spain;
| | - Melchor Riera
- Infectious Diseases Unit, Internal Medicine Department, Hospital Universitari Son Espases, Fundació Institut d’Investigació Sanitària Illes Balears (IdISBa), 07120 Palma de Mallorca, Spain;
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McCarroll TR, Jaggers RR, Cagle RA, Davis TE, Easton BL, Curless CT, Misamore GW. The incidence and incubation period of false-positive culture results in shoulder surgery. J Shoulder Elbow Surg 2021; 30:538-543. [PMID: 32650078 DOI: 10.1016/j.jse.2020.06.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 06/18/2020] [Accepted: 06/28/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Postoperative shoulder infection is a significant complication requiring timely identification and treatment. Indolent infections such as those involving Cutibacterium acnes (formerly Propionibacterium acnes) provide a diagnostic dilemma as they present differently, without the acute symptoms associated with most postoperative bone and joint infections. Furthermore, Cacnes is thought to be a common contaminant isolated from intraoperative cultures. With no consensus algorithm, long-held cultures play a major role in guiding management decisions in potential postoperative shoulder infection. Our study sought to determine the incidence of positive culture results in both open and arthroscopic procedures in noninfected patients, as well as to clarify whether an increase in the incubation time frame leads to an increased rate of culture growth. METHODS One hundred patients were prospectively enrolled into either the open or arthroscopic procedure group. Patients with abnormal inflammatory laboratory findings, a history of shoulder surgery, or corticosteroid injection within 6 months of surgery were excluded from the study. Three cultures were obtained for each patient: superficial tissue culture, tissue culture, and "sterile" control swab. Cultures were held for 28 days and checked at regular intervals. All patients were followed up clinically for 6 months to ensure no signs of postoperative infection occurred. RESULTS Ultimately, 95 patients were included in the final analysis. The false-positive rate was 17.0% in those who underwent open shoulder surgery and 10.4% in those who underwent arthroscopic shoulder surgery. The incidence of positive Cacnes culture results was 6.4% in the open group, whereas Cacnes was not isolated in the arthroscopic group. All positive bacterial culture results were reported within 7 days of collection. One culture result was positive for mold at 26 days. CONCLUSION A relatively high false-positive culture rate occurred in both open and arthroscopic shoulder surgery. Cacnes was the most commonly identified bacterium in cultures in the open surgery group. Knowledge of one's institutional false-positive culture rate could be important in avoiding potentially inappropriate treatment. Additionally, we found that holding cultures longer than 14 days did not lead to an increased rate of false-positive culture results.
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Affiliation(s)
| | | | | | - Thomas E Davis
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Brenda L Easton
- Methodist Sports Medicine Research and Education Foundation, Indianapolis, IN, USA
| | - Chris T Curless
- Methodist Sports Medicine Research and Education Foundation, Indianapolis, IN, USA
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Cutibacterium acnes infections in revision surgery for persistent shoulder complaints: a retrospective cohort study. Arch Orthop Trauma Surg 2021; 141:197-205. [PMID: 32232618 DOI: 10.1007/s00402-020-03415-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Low-grade Cutibacterium acnes (C. acnes) infections after shoulder surgery usually result in unexplained complaints. The absence of clinical signs of infection makes the incidence unclear and underreported. This study aimed to determine the incidence of C. acnes infections in patients with artificial material and unexplained persistent shoulder complaints. We hypothesized that the incidence of C. acnes infections would be higher in patients with artificial material. Risk factors and associations between culture time and contaminations/infections were also assessed. MATERIALS AND METHODS This retrospective cohort study included patients with and without artificial material undergoing revision shoulder surgery for persistent complaints after primary surgery and the suspicion of a low-grade infection. Three-six cultures were taken in all patients. C. acnes infection incidence was determined and logistic regression analysis was performed to identify risk factors. The association between time to culture growth and infections/contaminations was evaluated using Kaplan-Meier analysis and log-rank test. RESULTS 26/61 (42.6%) patients with and 14/33 (42.2%) without material had a C. acnes infection. Age (OR 0.959; 95% CI 0.914-1.000) and BMI (OR 0.884; 95% CI 0.787-0.977) were risk factors. Time to C. acnes culture positivity was not different between infections and contaminations. CONCLUSION The incidence of C. acnes infections was 42.6% in patients with artificial material and 42.2% in patients without artificial material. Younger age and lower BMI are risk factors. Low-grade C. acnes infections should be considered in patients with unexplained persistent complaints following shoulder surgery.
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Ruling out underlying infection in 200 presumed aseptic knee and hip revision arthroplasties using a multiplex PCR system. Eur J Clin Microbiol Infect Dis 2021; 40:1283-1290. [PMID: 33479882 DOI: 10.1007/s10096-021-04155-z] [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: 09/06/2020] [Accepted: 01/07/2021] [Indexed: 10/22/2022]
Abstract
Ruling out an infection in one-stage knee and hip revisions for presumed aseptic failure by conventional tissue cultures takes up to 14 days. Multiplex polymerase chain reaction (mPCR) is a quick test (4-5 h) for detecting pathogens. The purpose of this study was to evaluate the diagnostic accuracy of an automated mPCR of synovial fluid obtained intraoperatively in unsuspected knee and hip revisions. A prospective study was conducted with 200 patients undergoing a one-stage knee or hip revision. Synovial fluid was analyzed with the mPCR Unyvero implant and tissue infection G2 cartridge (U-ITI G2) system and compared to intraoperative tissue cultures. The primary outcome measure was the diagnostic accuracy, including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), of the mPCR U-ITI G2 system compared to conventional cultures. In the knee revision group, there were no patients with a positive mPCR in combination with positive cultures. This resulted in a non-calculable sensitivity and PPV. The specificity and NPV in the knee revision group of the mPCR compared to tissue cultures was 96.8% and 96.8%, respectively. In the hip revision group, the sensitivity, specificity, PPV, and NPV of the mPCR compared to tissue cultures was 36.4%, 96.6%, 57.1%, and 92.5%, respectively. Sixteen mismatches occurred between the mPCR and tissue cultures. The mPCR U-ITI G2 system is a quick and reliable synovium fluid test for ruling out infection in presumed aseptic knee and hip revisions with a high NPV compared with tissue cultures, although some mismatches were observed. Periprosthetic tissue cultures are still advised as back-up for false negative and positive mPCR test results.
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Behera HS, Chayani N, Bal M, Khuntia HK, Pati S, Das S, Ranjit M. Identification of population of bacteria from culture negative surgical site infection patients using molecular tool. BMC Surg 2021; 21:28. [PMID: 33413260 PMCID: PMC7788737 DOI: 10.1186/s12893-020-01016-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 12/15/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Managing surgical site infections, with negative culture report in routine diagnosis is a common dilemma in microbiology accounting more than 30% worldwide. The present study attempted to identify the presence of bacterial spp. if any in wound aspirates/swabs of culture negative surgical site infections of hospitalised patients using molecular tools. METHODS Ninety-seven patients with post-operative SSI whose wound swabs/aspirate were negative in the conventional aerobic culture after 72 h of incubation were analysed by 16S rRNA gene specific broad range PCR. The amplified DNA fragments were sequenced by Sanger DNA sequencing method and homology of the sequence were matched using NCBI BLAST (NCBI, USA) RESULTS: Of the 97 patients, 16S rRNA based broad range PCR assay could identify the presence of bacterial pathogen in 53(54.63%) cases, of which 29 isolates were supposed to be of viable but non-culturable bacteria (VBNC), 07 were of obligatory anaerobes and 13 were of unculturable bacteria, 04 were with poly bacterial infections. CONCLUSIONS Our study highlights the usefulness of PCR assay in detecting the presence of any VBNC, anaerobes and unculturable bacteria in SSI patients regardless of how well the bacteria may or may not grow in culture. Measures should be taken to use anaerobic culture system and PCR diagnosis along with conventional culture to detect the VBNC and unculturable bacteria where Gram stain is positive for better patient care.
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Affiliation(s)
- Himanshu Sekhar Behera
- ICMR-Regional Medical Research Centre, Bhubaneswar, 751023, Odisha, India. .,Department of Molecular Epidemiology, ICMR-Regional Medical Research Centre, Bhubaneswar, 751023, India.
| | - Nirupama Chayani
- Department of Microbiology, SCB Medical College and Hospital, Cuttack, 753003, India
| | - Madhusmita Bal
- Department of Parasite Immunology, ICMR-Regional Medical Research Centre, Bhubaneswar, 751023, India
| | - Hemant Kumar Khuntia
- Department of Molecular Epidemiology, ICMR-Regional Medical Research Centre, Bhubaneswar, 751023, India
| | - Sanghamitra Pati
- Department of Public Health, ICMR-Regional Medical Research Centre, Bhubaneswar, India
| | - Sashibhusan Das
- Department of Molecular Epidemiology, ICMR-Regional Medical Research Centre, Bhubaneswar, 751023, India
| | - Manoranjan Ranjit
- ICMR-Regional Medical Research Centre, Bhubaneswar, 751023, Odisha, India. .,Department of Molecular Epidemiology, ICMR-Regional Medical Research Centre, Bhubaneswar, 751023, India.
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Eyre-Brook AI, Gandhi MJ, Gopinath P, Jones V, Williams E, Townsend R, Booker S, Thyagarajan D, Stanley D, Ali AA. Revision total elbow arthroplasty: Is it safe to perform a single-stage revision for presumed aseptic loosening based on clinical assessment, normal inflammatory markers, and a negative aspiration? J Shoulder Elbow Surg 2021; 30:140-145. [PMID: 32534211 DOI: 10.1016/j.jse.2020.05.017] [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: 01/02/2020] [Revised: 05/05/2020] [Accepted: 05/12/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Revision total elbow arthroplasty (TEA) is a challenging procedure that is becoming increasingly common. In our unit, we regard it as essential to exclude infection as the underlying cause of TEA loosening. In all patients with arthroplasty loosening, we undertake a careful history and examination, perform radiographs, monitor inflammatory markers, and undertake a joint aspiration. If any investigation suggests infection as the etiology, then a 2-stage revision is undertaken. Open biopsies are not routinely performed. The aim was to ascertain from our outcomes whether it is safe to perform a single-stage revision for presumed aseptic loosening using these criteria. METHODS A retrospective review of a consecutive series of revision TEAs was performed in our unit over a 10-year period (2008-2018). Single-stage revisions performed for presumed aseptic loosening were identified. Case notes, radiographs, bloods, aspiration results, and microbiology of tissue samples taken at revision were reviewed. RESULTS A total of 123 revision elbow arthroplasty cases were performed in the study period. Sixty cases were revised for preoperatively proven infection, instability, or implant failure and were excluded from this study. In 63 cases, aseptic loosening was diagnosed based on history, clinical examination, blood markers, and aspiration. There were 21 dual-component and 42 single-component revisions. In the dual-component revision group, tissue samples taken at the time of revision were positive in only 1 case (5%). In the single-component revision group, positive culture samples were present in 3 cases (7%). χ2 analysis showed no significant difference between single- and dual-component revisions (P = .76). No cases with positive culture samples from either group have required subsequent revision surgery. CONCLUSION Given the results of this study, we conclude that is safe to perform single-stage revision arthroplasty for implant loosening based on history, examination, normal inflammatory markers, and negative aspiration results without the need for open biopsy.
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Affiliation(s)
- Alistair I Eyre-Brook
- Shoulder and Elbow Orthopaedic Department, Northern General Hospital, Sheffield, UK.
| | - Maulik J Gandhi
- Shoulder and Elbow Orthopaedic Department, Northern General Hospital, Sheffield, UK
| | - Praveen Gopinath
- Shoulder and Elbow Orthopaedic Department, Northern General Hospital, Sheffield, UK
| | - Val Jones
- Shoulder and Elbow Orthopaedic Department, Northern General Hospital, Sheffield, UK
| | - Emma Williams
- Microbiology Department, Northern General Hospital, Sheffield, UK
| | - Robert Townsend
- Microbiology Department, Northern General Hospital, Sheffield, UK
| | - Simon Booker
- Shoulder and Elbow Orthopaedic Department, Northern General Hospital, Sheffield, UK
| | - David Thyagarajan
- Shoulder and Elbow Orthopaedic Department, Northern General Hospital, Sheffield, UK
| | - David Stanley
- Shoulder and Elbow Orthopaedic Department, Northern General Hospital, Sheffield, UK
| | - Amjid A Ali
- Shoulder and Elbow Orthopaedic Department, Northern General Hospital, Sheffield, UK
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Hudek R, Brobeil A, Brüggemann H, Sommer F, Gattenlöhner S, Gohlke F. Cutibacterium acnes is an intracellular and intra-articular commensal of the human shoulder joint. J Shoulder Elbow Surg 2021; 30:16-26. [PMID: 32741563 DOI: 10.1016/j.jse.2020.04.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 04/03/2020] [Accepted: 04/12/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Cutibacterium acnes (C acnes) is a mysterious member of the shoulder microbiome and is associated with chronic postoperative complications and low-grade infections. Nevertheless, it is unclear whether it represents a contaminant or whether it accounts for true infections. Because it can persist intracellularly in macrophages at several body sites, it might in fact be an intra-articular commensal of the shoulder joint. METHODS In 23 consecutive, otherwise healthy patients (17 male, 6 female; 58 years) who had no previous injections, multiple specimens were taken from the intra-articular tissue during first-time arthroscopic and open shoulder surgery. The samples were investigated by cultivation, genetic phylotyping, and immunohistochemistry using C acnes-specific antibodies and confocal laser scanning microscopy. RESULTS In 10 patients (43.5%), cultures were C acnes-positive. Phylotype IA1 dominated the subcutaneous samples (71%), whereas type II dominated the deep tissue samples (57%). Sixteen of 23 patients (69.6%) were C acnes-positive by immunohistochemistry; in total, 25 of 40 samples were positive (62.5%). Overall, 56.3% of glenohumeral immunohistochemical samples, 62.5% of subacromial samples, and 75% of acromioclavicular (AC) joint samples were positive. In 62.5% of the tested patients, C acnes was detected immunohistochemically to reside intracellularly within stromal cells and macrophages. DISCUSSION These data indicate that C acnes is a commensal of the human shoulder joint, where it persists within macrophages and stromal cells. Compared with culture-based methods, immunohistochemical staining can increase C acnes detection. Phylotype II seems to be most prevalent in the deep shoulder tissue. The high detection rate of C acnes in osteoarthritic AC joints might link its intra-articular presence to the initiation of osteoarthritis.
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Affiliation(s)
- Robert Hudek
- Rhön-Klinikum Campus Bad Neustadt, Department for Shoulder and Elbow Surgery, Bad Neustadt a. d. Saale, Germany.
| | - Alexander Brobeil
- Justus-Liebig-University Gießen, Institute for Pathology, Gießen, Germany
| | | | - Frank Sommer
- Phillipps-University Marburg, Institute for Medical Microbiology and Hospital Hygiene, Marburg, Germany
| | | | - Frank Gohlke
- Rhön-Klinikum Campus Bad Neustadt, Department for Shoulder and Elbow Surgery, Bad Neustadt a. d. Saale, Germany
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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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