Development of a Novel and Rapid Antibody-Based Diagnostic for Chronic Staphylococcus aureus Infections Based on Biofilm Antigens

Commercial Synovial Antigen Testing is Inferior to Traditional Culture for the Diagnosis of Periprosthetic Joint Infection in Patients Undergoing Revision Total Knee Arthroplasty

BACKGROUND

Despite its limitations, a culture remains the "gold standard" for pathogen identification in patients who have periprosthetic joint infection (PJI). Recently, a synovial fluid antigen test has been introduced by a commercial entity. The purpose of this multicenter study was to determine the accuracy of the antigen test in the diagnosis of PJI.

METHODS

This retrospective study identified 613 patients undergoing revision total knee arthroplasty who had undergone preoperative synovial fluid analysis. A PJI was defined using the 2018 International Consensus Meeting (ICM) criteria. Patients who had an extended period (> 180 days) from aspiration to revision procedure (n = 62), those presenting within 90 days of their index arthroplasty procedure (n = 17), and patients who had an inconclusive ICM score (n = 8) were excluded. Using receiver operator characteristic curve analyses, we examined the utility of the microbial identification (MID) antigen test and any positive culture (either preoperative or intraoperative) in the diagnosis of PJI.

RESULTS

A total of 526 patients were included. Of these, 125 (23.8%) were ICM positive and 401 (76.2%) were ICM negative. Culture demonstrated an area under the curve (AUC) of 0.864, sensitivity of 75.2%, and specificity of 97.5%. On the other hand, the MID test exhibited an AUC of 0.802, sensitivity of 61.6%, and specificity of 98.8%. The AUC of culture was significantly higher than that of the MID test (P = .037). The MID test was positive in 41.9% of culture-negative PJI cases. We also observed a high rate of discordance (29.7%) when both culture and the MID test were positive in the ICM-positive group.

CONCLUSIONS

Synovial fluid antigen testing does not provide additional clinical benefit when compared to traditional cultures for the diagnosis of PJI. The antigen test had low sensitivity in the diagnosis of PJI and a relatively high rate of discordance with culture.

LEVEL OF EVIDENCE

Level III.

Commercial Synovial Antibody Testing is No Better Than Traditional Culture in Identification of Pathogen(s) Causing Periprosthetic Joint Infection

BACKGROUND

Identification of infective organism causing periprosthetic joint infections (PJIs) is crucial to tailor the best combination of surgical and antimicrobial treatment. Traditional culture, with all its limitations, has been utilized for this purpose. A synovial fluid antibody assay against some common pathogens has been introduced by a commercial entity recently. This study aimed to determine if the antibody testing could be used as a proxy to traditional culture, and whether it provided additional information, in the setting of PJI.

METHODS

A retrospective study was conducted of patients who underwent revision total hip and knee arthroplasty between January 2019 and 2020. Aspirated synovial fluid was sent for analyses including the commercial antibody testing. All patients had samples harvested for culture per standard of care. Results of the antibody testing and culture, in terms of concordance, were compared. Receiver operating characteristic curve and Youden's criterion were used to compare the 2 methods.

RESULTS

A total of 419 patients were included. Using the International Consensus Meeting criteria as reference standard for PJI, antibody testing had a sensitivity and specificity of 40.5% and 93.4%, respectively. There were 59.5% false negative results with antibody testing compared with 50% for culture. Of the 12 patients who had positive results in both tests, 5 (41.7%) had discordant pathogens identified in each test.

CONCLUSION

Synovial fluid antibody testing does not provide clinical benefit when compared to traditional cultures for PJI diagnosis. The antibody testing had a low sensitivity and a high rate of discordance with culture, when both tests were positive.

Novel strategies to diagnose prosthetic or native bone and joint infections

INTRODUCTION

Bone and Joint Infections (BJI) are medically important, costly and occur in native and prosthetic joints. Arthroplasties will increase significantly in absolute numbers over time as well as the incidence of Prosthetic Joint Infections (PJI). Diagnosis of BJI and PJI is sub-optimal. The available diagnostic tests have variable effectiveness, are often below standard in sensitivity and/or specificity, and carry significant contamination risks during the collection of clinical samples. Improvement of diagnostics is urgently needed.

AREAS COVERED

We provide a narrative review on current and future diagnostic microbiology technologies. Pathogen identification, antibiotic resistance detection, and assessment of the epidemiology of infections via bacterial typing are considered useful for improved patient management. We confirm the continuing importance of culture methods and successful introduction of molecular, mass spectrometry-mediated and next-generation genome sequencing technologies. The diagnostic algorithms for BJI must be better defined, especially in the context of diversity of both disease phenotypes and clinical specimens rendered available.

EXPERT OPINION

Whether interventions in BJI or PJI are surgical or chemo-therapeutic (antibiotics and bacteriophages included), prior sensitive and specific pathogen detection remains a therapy-substantiating necessity. Innovative tests for earlier and more sensitive and specific detection of bacterial pathogens in BJI are urgently needed.

Biofilm control by ionic liquids

Ionic liquids (ILs) are remarkable chemical compounds with applications in many areas of modern science. They are increasingly recognized as promising compounds to fight microorganisms in both planktonic and biofilm states, contributing to reinvent the antimicrobial pipeline. Biofilm-related infections are particularly challenging given that the scientific community has not yet identified a reliable control strategy. Understanding of the action of ILs in biofilm control is is still in a very early stage. However, given the highly tunable nature and exceptional properties of ILs, they are excellent candidates for biofilm control. Here, we review the major advances in, and challenges tothe use of ILs for effective biofilm control.

A Bioinformatic Approach to Utilize a Patient's Antibody-Secreting Cells against Staphylococcus aureus to Detect Challenging Musculoskeletal Infections

Noninvasive diagnostics for Staphylococcus aureus musculoskeletal infections (MSKI) remain challenging. Abs from newly activated, pathogen-specific plasmablasts in human blood, which emerge during an ongoing infection, can be used for diagnosing and tracking treatment response in diabetic foot infections. Using multianalyte immunoassays on medium enriched for newly synthesized Abs (MENSA) from Ab-secreting cells, we assessed anti-S. aureus IgG responses in 101 MSKI patients (63 culture-confirmed S. aureus, 38 S. aureus-negative) and 52 healthy controls. MENSA IgG levels were assessed for their ability to identify the presence and type of S. aureus MSKI using machine learning and multivariate receiver operating characteristic curves. Eleven S. aureus-infected patients were presented with prosthetic joint infections, 15 with fracture-related infections, 5 with native joint septic arthritis, 15 with diabetic foot infections, and 17 with suspected orthopedic infections in the soft tissue. Anti-S. aureus MENSA IgG levels in patients with non-S. aureus infections and healthy controls were 4-fold (***p = 0.0002) and 8-fold (****p < 0.0001) lower, respectively, compared with those with culture-confirmed S. aureus infections. Comparison of MENSA IgG responses among S. aureus culture-positive patients revealed Ags predictive of active MSKI (IsdB, SCIN, Gmd) and Ags predictive of MSKI type (IsdB, IsdH, Amd, Hla). When combined, IsdB, IsdH, Gmd, Amd, SCIN, and Hla were highly discriminatory of S. aureus MSKI (area under the ROC curve = 0.89 [95% confidence interval 0.82-0.93, p < 0.01]). Collectively, these results demonstrate the feasibility of a bioinformatic approach to use a patient's active immune proteome against S. aureus to diagnose challenging MSKI.