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Henssler L, Schellenberger L, Baertl S, Klute L, Heyd R, Kerschbaum M, Alt V, Popp D. Time to Positivity in Blood Culture Bottles Inoculated with Sonication Fluid from Fracture-Related Infections. Microorganisms 2024; 12:862. [PMID: 38792692 PMCID: PMC11123396 DOI: 10.3390/microorganisms12050862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 05/26/2024] Open
Abstract
The timely and accurate identification of causative agents is crucial for effectively managing fracture-related infections (FRIs). Among various diagnostic methods, the "time to positivity" (TTP) of cultures has emerged as a valuable predictive factor in infectious diseases. While sonication of implants and inoculation of blood culture bottles with sonication fluid have enhanced sensitivity, data on the TTP of this microbiological technique remain limited. Therefore, patients with ICM criteria for confirmed FRI treated at our institution between March 2019 and March 2023 were retrospectively identified and their microbiological records were analyzed. The primary outcome parameter was TTP for different microorganism species cultured in a liquid culture collected from patients with confirmed FRI. A total of 155 sonication fluid samples from 126 patients (average age 57.0 ± 17.4 years, 68.3% males) was analyzed. Positive bacterial detection was observed in 78.7% (122/155) of the liquid culture pairs infused with sonication fluid. Staphylococcus aureus was the most prevalent organism (42.6%). Streptococcus species exhibited the fastest TTP (median 11.9 h), followed by Staphylococcus aureus (median 12.1 h) and Gram-negative bacteria (median 12.5 h), all of which had a 100% detection rate within 48 h after inoculation. Since all Gram-negative pathogens yielded positive culture results within 24 h, it could be discussed if empirical antibiotic therapy could be de-escalated early and limited towards the Gram-positive germ spectrum if no Gram-negative pathogens are detected up to this time point in the context of antibiotic stewardship.
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Affiliation(s)
- Leopold Henssler
- Department of Trauma Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Lena Schellenberger
- Department of Trauma Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Susanne Baertl
- Department of Trauma Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Lisa Klute
- Department of Trauma Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Robert Heyd
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Maximilian Kerschbaum
- Department of Trauma Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Volker Alt
- Department of Trauma Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Daniel Popp
- Department of Trauma Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
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Trenkwalder K, Erichsen S, Weisemann F, Augat P, Militz M, von Rüden C, Hentschel T, Hackl S. The value of sonication in the differential diagnosis of septic and aseptic femoral and tibial shaft nonunion in comparison to conventional tissue culture and histopathology: a prospective multicenter clinical study. J Orthop Traumatol 2023; 24:25. [PMID: 37308767 DOI: 10.1186/s10195-023-00708-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 05/07/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Septic and aseptic nonunion require different therapeutic strategies. However, differential diagnosis is challenging, as low-grade infections and biofilm-bound bacteria often remain undetected. Therefore, the examination of biofilm on implants by sonication and the evaluation of its value for differentiating between femoral or tibial shaft septic and aseptic nonunion in comparison to tissue culture and histopathology was the focus of this study. MATERIALS AND METHODS Osteosynthesis material for sonication and tissue samples for long-term culture and histopathologic examination from 53 patients with aseptic nonunion, 42 with septic nonunion and 32 with regular healed fractures were obtained during surgery. Sonication fluid was concentrated by membrane filtration and colony-forming units (CFU) were quantified after aerobic and anaerobic incubation. CFU cut-off values for differentiating between septic and aseptic nonunion or regular healers were determined by receiver operating characteristic analysis. The performances of the different diagnostic methods were calculated using cross-tabulation. RESULTS The cut-off value for differentiating between septic and aseptic nonunion was ≥ 13.6 CFU/10 ml sonication fluid. With a sensitivity of 52% and a specificity of 93%, the diagnostic performance of membrane filtration was lower than that of tissue culture (69%, 96%) but higher than that of histopathology (14%, 87%). Considering two criteria for infection diagnosis, the sensitivity was similar for one tissue culture with the same pathogen in broth-cultured sonication fluid and two positive tissue cultures (55%). The combination of tissue culture and membrane-filtrated sonication fluid had a sensitivity of 50%, which increased up to 62% when using a lower CFU cut-off determined from regular healers. Furthermore, membrane filtration demonstrated a significantly higher polymicrobial detection rate compared to tissue culture and sonication fluid broth culture. CONCLUSIONS Our findings support a multimodal approach for the differential diagnosis of nonunion, with sonication demonstrating substantial usefulness. LEVEL OF EVIDENCE Level 2 Trial registration DRKS00014657 (date of registration: 2018/04/26).
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Affiliation(s)
- Katharina Trenkwalder
- Institute for Biomechanics, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau am Staffelsee, Germany
- Institute for Biomechanics, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Austria
| | - Sandra Erichsen
- Institute for Biomechanics, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau am Staffelsee, Germany
- Institute for Biomechanics, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Austria
| | - Ferdinand Weisemann
- Department of Trauma Surgery, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau am Staffelsee, Germany
| | - Peter Augat
- Institute for Biomechanics, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau am Staffelsee, Germany
- Institute for Biomechanics, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Austria
| | - Matthias Militz
- Department of Trauma Surgery, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau am Staffelsee, Germany
| | - Christian von Rüden
- Institute for Biomechanics, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Austria
- Department of Trauma Surgery, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau am Staffelsee, Germany
| | - Tobias Hentschel
- Department of Trauma Surgery, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau am Staffelsee, Germany
| | - Simon Hackl
- Institute for Biomechanics, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Austria.
- Department of Trauma Surgery, BG Unfallklinik Murnau, Professor-Küntscher-Str. 8, 82418, Murnau am Staffelsee, Germany.
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Hirata BHN, Sasagawa S, Navarini A, Mateus HC, Pacheco Junior AM, Salles MJC. Comparison of bacterial profile of gallbladder with gallstones from patients undergoing cholecystectomy due to complicated and uncomplicated cholelithiasis: changes in the epidemiological scenario. Rev Col Bras Cir 2023; 50:e20233474. [PMID: 37162041 PMCID: PMC10508671 DOI: 10.1590/0100-6991e-20233474-en] [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: 09/19/2022] [Accepted: 02/07/2023] [Indexed: 05/11/2023] Open
Abstract
INTRODUCTION cholelithiasis is a highly prevalent disease of the digestive system in the world. In Brazil, it is a routine condition, whose studies suggest a prevalence of around 10% of adults. Colonization of bile and gallstone pathogens can occur when there is bacterial stasis and proliferation. This proliferation is facilitated by the adhesion and biofilm formation capacity of some bacteria. There are also lithogenic processes that involve bacterial participation. Studies have shown changes in the microbiota of the gallbladder of patients undergoing cholecystectomy, which may impact empirical treatment with antibiotics. METHODOLOGY microbiological analyzes of the sonication fluid of the gallstones and of two samples with bile were performed. Identification and antimicrobial susceptibility testing were performed according to a standard routine. RESULTS of the 34 patients, 76.4% were female. The age group was 48 years +/- 16.61. Acute cholecystitis occurred in 50% of cases. Bactobilia was evidenced in 32.1% of the cases. Klebisiella pneumoniae was noted as the most prevalent pathogen in acute cholecystitis; and Enterobacter sp, in cases of uncomplicated cholelithiasis. Greater sensitivity was obtained in the search for microorganisms in the sonication fluid samples of the stones in relation to the bile samples (p=0.0058). CONCLUSION there was a higher prevalence of bactobilia in patients with acute cholecystitis compared to those with uncomplicated cholelithiasis. The use of sonication in bacterial investigation proved to be superior to the conventional method and can be considered.
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Affiliation(s)
| | - Suzethe Sasagawa
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Microbiologia - São Paulo - SP - Brasil
| | - Alessandra Navarini
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Microbiologia - São Paulo - SP - Brasil
| | - Henrique Cunha Mateus
- - Hospital de Misericórdia da Santa Casa de São Paulo, Cirurgia - São Paulo - SP - Brasil
| | | | - Mauro José Costa Salles
- - Hospital de Misericórdia da Santa Casa de São Paulo, Infectologia - São Paulo - SP - Brasil
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Inoculation of sonicate fluid into blood culture bottles improves microbial detection in patients with orthopedic bone and soft tissue infections of the upper and lower extremities. J Orthop Sci 2023; 28:476-483. [PMID: 34972615 DOI: 10.1016/j.jos.2021.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/16/2021] [Accepted: 11/12/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND The usefulness of sonicate fluid culture for biological tissues in orthopedic bone and soft tissue infections have not been reported. We assessed whether inoculating the sonicate fluid of bone and soft tissue into a blood culture bottle could increase the diagnostic accuracy for biofilm-related orthopedic infections. METHODS Twenty consecutive patients with infections (9 purulent arthritis, 4 osteomyelitis, 4 purulent tenosynovitis, 2 purulent bursitis, and 1 cellulitis) and 10 non-infected cases (6 carpal tunnel syndrome, 3 Dupuytren contracture, and 1 soft tissue tumor) between October 2018 and December 2020 were evaluated prospectively. We analyzed a total of 107 culture submissions (87 bone and tissue specimens and 20 controls); 42 intraoperative tissue specimens (32 infected samples and 10 non-infected samples) using the conventional method, 45 sonication samples (35 infected samples and 10 non-infected samples), and 20 control samples. Intraoperative infectious tissues were cultured using sonicate fluid culture in a blood culture bottle (SFC-CB). The applications of SFC-CB and the conventional culture method and the detection rate, sensitivity, and relationship between the sensitivity of the diagnostic methods and duration of administered preoperative antibiotics were assessed. RESULTS The causative microorganism was detected only by SFC-CB in five patients (25%). The sensitivity (85% vs. 60%; P = 0.077) and detection rate (80% vs. 60%; P = 0.065) were higher for SFC-CB than for the conventional culture method. The sensitivity of SFC-CB was significantly higher than that of the conventional culture method in cases in which preoperative antibiotics were administered for more than 1 week (77% vs. 39%; P = 0.047). CONCLUSIONS Using SFC-CB, the diagnostic accuracy for bone and soft tissue infection was significantly improved. As biofilms are readily formed in biological tissues, sonication may also be useful for diagnosis. SFC-CB was particularly useful for cases in which preoperative antibiotics were administered.
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Prior use of antibiotics and immunosuppression are risk factors for fracture-related infection during the COVID-19 pandemic period: a Brazilian prospective cohort study. BMC Musculoskelet Disord 2022; 23:535. [PMID: 35658853 PMCID: PMC9166157 DOI: 10.1186/s12891-022-05493-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/23/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Little is known about the role of COVID-19 pandemic period on the epidemiology of fracture-related infection (FRI). The present study summarizes the changes in the prevalence, microbiology, and risk factors of FRI during this period.
Methods
A prospective single-center cohort study assessed in the setting of COVID-19 pandemic (2020–2021), clinical, microbiological aspects, and independent risk factors (RF) of FRI. RFs were estimated by bivariate and multivariable analyses using prevalence ratio (PR) with significance at P < 0.05. Kaplan–Meier analysis was performed to evaluate treatment outcomes.
Results
Overall, 132 patients were analyzed, with patients with age over 65 years accounting 65.1%. FRI was diagnosed in 21(15.9%) patients. Independent RFs for FRI were recent and preoperative use of systemic antibiotics (PR: 7.0, 95% confidence interval (95% CI): 2.2 – 22.4, p = 0.001) and cancer (PR: 9.8, 95% CI: 2.0 – 48.8, p = 0.005). Cultures yielded Gram-negative bacteria in 77.8%, 33.3% were MDR.
Conclusions
We found higher rates of FRI, predominating in the elderly with closed femoral fractures during the COVID-19 pandemic. Prior use of antibiotics and immunosuppression conditions were independent factor for FRI. Our outcomes provide evidence to avoid the empirical use of antibiotics prior to surgery for fracture stabilization.
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Santos INM, Kurihara MNL, Santos FF, Valiatti TB, da Silva JTP, Pignatari ACC, Salles MJ. Comparative Phenotypic and Genomic Features of Staphylococci from Sonication Fluid of Orthopedic Implant-Associated Infections with Poor Outcome. Microorganisms 2022; 10:microorganisms10061149. [PMID: 35744667 PMCID: PMC9230661 DOI: 10.3390/microorganisms10061149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 05/25/2022] [Accepted: 05/27/2022] [Indexed: 11/16/2022] Open
Abstract
Staphylococcus spp. remain the leading biofilm-forming agents causing orthopedic implant-associated infections (OIAI). This is a descriptive study of phenotypic and genomic features identified in clinical isolates of S. aureus and coagulase-negative Staphylococcus (CoNS) recovered from OIAIs patients that progressed to treatment failure. Ten isolates were identified by matrix-time-of-flight laser-assisted desorption mass spectrometry (MALDI-TOF-MS) and tested for antibiotic susceptibility and biofilm formation. Genotypic characteristics, including, MLST (Multi Locus Sequence Typing), SCCmec typing, virulence and resistance genes were assessed by whole-genome sequencing (WGS). All S. aureus harbored mecA, blaZ, and multiple resistance genes for aminoglycosides and quinolones. All MRSA were strong biofilm producers harboring the complete icaADBC and icaR operon. Seven CoNS isolates comprising five species (S. epidermidis, S. haemolyticus, S. sciuri, S. capitis and S. lugdunensis) were analyzed, with mecA gene detected in five isolates. S. haemolitycus (isolate 95), and S. lugdunensis were unable to form biofilm and did not harbor the complete icaADBCR operon. High variability of adhesion genes was detected, with atl, ebp, icaADBC operon, and IS256 being the most common. In conclusion, MRSA and CoNS isolates carrying genes for biofilm production, and resistance to β-lactam and aminoglycosides are associated with treatment failure in OIAIs.
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Affiliation(s)
- Ingrid Nayara Marcelino Santos
- Laboratório Especial de Microbiologia (LEMC), Departamento de Medicina, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo 04025-010, Brazil; (I.N.M.S.); (M.N.L.K.); (A.C.C.P.)
| | - Mariana Neri Lucas Kurihara
- Laboratório Especial de Microbiologia (LEMC), Departamento de Medicina, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo 04025-010, Brazil; (I.N.M.S.); (M.N.L.K.); (A.C.C.P.)
| | - Fernanda Fernandes Santos
- Laboratório Alerta, Disciplina de Infectologia, Departamento de Medicina, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo 04039-032, Brazil; (F.F.S.); (T.B.V.); (J.T.P.d.S.)
| | - Tiago Barcelos Valiatti
- Laboratório Alerta, Disciplina de Infectologia, Departamento de Medicina, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo 04039-032, Brazil; (F.F.S.); (T.B.V.); (J.T.P.d.S.)
| | - Juliana Thalita Paulino da Silva
- Laboratório Alerta, Disciplina de Infectologia, Departamento de Medicina, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo 04039-032, Brazil; (F.F.S.); (T.B.V.); (J.T.P.d.S.)
| | - Antônio Carlos Campos Pignatari
- Laboratório Especial de Microbiologia (LEMC), Departamento de Medicina, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo 04025-010, Brazil; (I.N.M.S.); (M.N.L.K.); (A.C.C.P.)
| | - Mauro José Salles
- Laboratório Especial de Microbiologia (LEMC), Departamento de Medicina, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo 04025-010, Brazil; (I.N.M.S.); (M.N.L.K.); (A.C.C.P.)
- Faculdade de Ciências Médicas Santa Casa de São Paulo, São Paulo 01224-001, Brazil
- Hospital São Paulo, Universidade Federal de São Paulo (UNIFESP), São Paulo 04024-002, Brazil
- Correspondence: ; Tel.: +55-11-98536-0055
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Li J, Wong RMY, Chung YL, Leung SSY, Chow SKH, Ip M, Cheung WH. Fracture-related infection in osteoporotic bone causes more severe infection and further delays healing. Bone Joint Res 2022; 11:49-60. [PMID: 35100815 PMCID: PMC8882324 DOI: 10.1302/2046-3758.112.bjr-2021-0299.r1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Aims With the ageing population, fragility fractures have become one of the most common conditions. The objective of this study was to investigate whether microbiological outcomes and fracture-healing in osteoporotic bone is worse than normal bone with fracture-related infection (FRI). Methods A total of 120 six-month-old Sprague-Dawley (SD) rats were randomized to six groups: Sham, sham + infection (Sham-Inf), sham with infection + antibiotics (Sham-Inf-A), ovariectomized (OVX), OVX + infection (OVX-Inf), and OVX + infection + antibiotics (OVX-Inf-A). Open femoral diaphysis fractures with Kirschner wire fixation were performed. Staphylococcus aureus at 4 × 104 colony-forming units (CFU)/ml was inoculated. Rats were euthanized at four and eight weeks post-surgery. Radiography, micro-CT, haematoxylin-eosin, mechanical testing, immunohistochemistry (IHC), gram staining, agar plating, crystal violet staining, and scanning electron microscopy were performed. Results Agar plating analysis revealed a higher bacterial load in bone (p = 0.002), and gram staining showed higher cortical bone colonization (p = 0.039) in OVX-Inf compared to Sham-Inf. OVX-Inf showed significantly increased callus area (p = 0.013), but decreased high-density bone volume (p = 0.023) compared to Sham-Inf. IHC staining showed a significantly increased expression of TNF-α in OVX-Inf compared to OVX (p = 0.049). Significantly reduced bacterial load on bone (p = 0.001), enhanced ultimate load (p = 0.001), and energy to failure were observed in Sham-Inf-A compared to Sham-Inf (p = 0.028), but not in OVX-Inf-A compared to OVX-Inf. Conclusion In osteoporotic bone with FRI, infection was more severe with more bone lysis and higher bacterial load, and fracture-healing was further delayed. Systemic antibiotics significantly reduced bacterial load and enhanced callus quality and strength in normal bone with FRI, but not in osteoporotic bone. Cite this article: Bone Joint Res 2022;11(2):49–60.
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Affiliation(s)
- Jie Li
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong, China
| | - Ronald Man Yeung Wong
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong, China
| | - Yik Lok Chung
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong, China
| | | | - Simon Kwoon-Ho Chow
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong, China
| | - Margaret Ip
- Department of Microbiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Wing-Hoi Cheung
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong, China
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Single-stage total hip arthroplasty after failed fixation of proximal femoral fractures: an increased risk for periprosthetic joint infections? Arch Orthop Trauma Surg 2022; 142:2911-2917. [PMID: 34453205 PMCID: PMC9474588 DOI: 10.1007/s00402-021-04119-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 08/09/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Higher complication rates have been reported for total hip arthroplasty (THA) after osteosynthesis of proximal femur fractures (PFF). This study evaluated the infection risk for conversion of internal fixation of PFF to THA by a single-staged procedure in the absence of clear infection signs. METHODS Patients undergoing a one-staged conversion to THA (2013-2018) after prior internal fixation of the proximal femur were included. Preoperative diagnostics with laboratory results, hip aspirations as well as intraoperative microbiology and sonication were assessed. Postoperative complications were recorded as well as patient demographics, duration between initial and conversion to THA, explanted osteosynthesis and implanted THA. RESULTS Fifty-eight patients (24 male/34 female, 62.8 ± 14.5 years) were included with a mean time of 3.8 ± 7.5 years between internal fixation and conversion to THA (45 cementless, 3 cemented, 3 hybrid and 7 hybrid inverse THAs). Preoperative mean blood level CRP was 8.36 ± 14 mg/l (reference value < 5 mg/l) and leukocyte count was 7.11 ± 1.84^3/µl (4.5-10.000^3/µl). Fifty patients had intraoperative microbiological diagnostics, with either swabs in 86.2% and/or sonication in 29.3%. Positive microbiological results were recorded in 10% (5 of 50 patients), with pathogens identified being mainly Staphylococcus. Complications after conversion occurred in 9.6% including a postoperative low-grade infection rate of 5.8% after a mean of 2.5 years. CONCLUSION This study found a positive microbiological test result in 10% of a one-stage conversion of PFF fixation to THA. Moreover, we found a high infection rate (5.8%) for early postoperative periprosthetic joint infection. Interestingly, CRP has not been proven to be an adequate parameter for low-grade infections or occult colonized implants. Therefore, we recommend a comprehensive pre- and intraoperative diagnostic including hip aspiration, swabs and sonication when considering one-staged revision.
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El-Ashry AH, Hussein MSA, Saad K, El Elhoufey A. Clinical utility of sonication for diagnosing infection and colonization of cardiovascular implantable electronic devices. Med Microbiol Immunol 2021; 210:245-250. [PMID: 34254192 DOI: 10.1007/s00430-021-00717-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 07/05/2021] [Indexed: 02/08/2023]
Abstract
Our study aimed to evaluate the sensitivity of the sonication tool for the microbiological diagnosis of cardiovascular implantable electronic device infections (CIEDIs). The extracted cardiac implants of 52 patients were assessed: 19 with CIEDI and 33 with elective generator replacement or revision without clinical infection. Sonication fluid culture of explanted CIEDs yielded higher numbers of microorganisms than pocket tissue or swab cultures. The sensitivity of sonication fluid culture was significantly higher than that of pocket swab and tissue culture for microbiological diagnosis of CIEDI. The microorganisms isolated most frequently via sonication of explanted CIEDs were Gram-positive cocci (70%), of which 50% was coagulase-negative Staphylococcus. Sonication fluid culture detected colonization in 36.4% of the non-infected patients. Sonication fluid culture represents a promising diagnostic strategy with increased sensitivity compared to conventional culture methods for microbiological diagnosis of cardiac devices associated with infection and colonization.
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Affiliation(s)
- Amira H El-Ashry
- Medical Microbiology and Immunology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | | | - Khaled Saad
- Pediatrics, Faculty of Medicine, Assiut University, Assiut, 71516, Egypt.
| | - Amira El Elhoufey
- Department of Community Health Nursing, Faculty of Nursing, Assiut University, Assiut, Egypt
- Department of Community Health Nursing, Alddrab University College, Jazan University, Jazan, Kingdom of Saudi Arabia
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Implant removal of osteosynthesis. Results of a survey among Spanish orthopaedic surgeons. Rev Esp Cir Ortop Traumatol (Engl Ed) 2021. [DOI: 10.1016/j.recote.2021.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Ribeiro TC, Honda EK, Daniachi D, Cury RDPL, da Silva CB, Klautau GB, Salles MJ. The impact of sonication cultures when the diagnosis of prosthetic joint infection is inconclusive. PLoS One 2021; 16:e0252322. [PMID: 34255768 PMCID: PMC8277053 DOI: 10.1371/journal.pone.0252322] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 05/13/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND In the absence of a gold standard criterion for diagnosing prosthetic joint infections (PJI), sonication of the removed implant may provide superior microbiological identification to synovial fluid and peri-implant tissue cultures. The aim of this retrospective study was to assess the role of sonication culture compared to tissue cultures for diagnosing PJI, using different consensus and international guidelines for PJI definition. METHODS Data of 146 patients undergoing removal of hip or knee arthroplasties between 2010 and 2018 were retrospectively reviewed. The International Consensus Meeting (ICM-2018), Musculoskeletal Infection Society (MSIS), Infectious Diseases Society of America (IDSA), the European Bone and Joint Infection Society (EBJIS), and a modified clinical criterion, were used to compare the performance of microbiological tests. McNemar´s test and proportion comparison were employed to calculate p-value. RESULTS Overall, 56% (82/146) were diagnosed with PJI using the clinical criteria. Out of these cases, 57% (47/82) tested positive on tissue culture and 93% (76/82) on sonication culture. Applying this clinical criterion, the sensitivity of sonication fluid and tissue cultures was 92.7% (95% CI: 87.1%- 98.3%) and 57.3% (95% CI: 46.6%-68.0%) (p<0.001), respectively. When both methods were combined for diagnosis (sonication and tissue cultures) sensitivity reached 96.3% (95% CI: 91.5%-100%). Sonication culture and the combination of sonication with tissue cultures, showed higher sensitivity rates than tissue cultures alone for all diagnostic criteria (ICM-18, MSIS, IDSA and EBJIS) applied. Conversely, tissue culture provided greater specificity than sonication culture for all the criteria assessed, except for the EBJIS criteria, in which sonication and tissue cultures specificity was 100% and 95.3% (95% CI: 87.8-100%), respectively (p = 0.024). CONCLUSIONS In a context where diagnostic criteria available have shortcomings and tissue cultures remain the gold standard, sonication cultures can aid PJI diagnosis, especially when diagnostic criteria are inconclusive due to some important missing data (joint puncture, histology).
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Affiliation(s)
- Taiana Cunha Ribeiro
- Internal Medicine Department, Infectious Diseases Clinic, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - Emerson Kiyoshi Honda
- Orthopedic and Traumatology Department, Irmandade Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
| | - Daniel Daniachi
- Orthopedic and Traumatology Department, Irmandade Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
| | - Ricardo de Paula Leite Cury
- Orthopedic and Traumatology Department, Irmandade Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
| | - Cely Barreto da Silva
- Department of Laboratory Medicine and Pathology, Irmandade Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
| | - Giselle Burlamaqui Klautau
- Internal Medicine Department, Infectious Diseases Clinic, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - Mauro Jose Salles
- Internal Medicine Department, Infectious Diseases Clinic, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
- Escola Paulista de Medicina, Universidade Federal de São Paulo, Division of Infection Diseases, São Paulo, Brazil
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12
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Sousa R, Carvalho A, Santos AC, Abreu MA. Optimal microbiological sampling for the diagnosis of osteoarticular infection. EFORT Open Rev 2021; 6:390-398. [PMID: 34267930 PMCID: PMC8246105 DOI: 10.1302/2058-5241.6.210011] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Infection is a dire complication afflicting every field of orthopaedics and traumatology. If specific clinical, laboratory and imaging parameters are present, infection is often assumed even in the absence of microbiological confirmation. However, apart from confirming infection, knowing the exact infecting pathogen(s) and their antimicrobial susceptibility patterns is paramount to help guide treatment. Every effort should therefore be undertaken with that goal in mind.Not all microbiological findings carry the same relevance, and knowing exactly how and where a sample was collected is key. Several different sampling techniques are available, and one must be aware of both advantages and limitations. Microbiological sampling alternatives in some of the most common clinical scenarios such as native and prosthetic joint infections, osteomyelitis and fracture-related infections, spinal and diabetic foot infections will be discussed.Orthopaedic surgeons should also be aware of basic laboratory sample processing techniques as they have a direct impact on the way specimens should be dealt with and transported to the laboratory. Only by knowing these basic principles will surgeons be able to participate in the multidisciplinary discussion and decision making around how to interpret microbiological findings in each specific patient. Cite this article: EFORT Open Rev 2021;6:390-398. DOI: 10.1302/2058-5241.6.210011.
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Affiliation(s)
- Ricardo Sousa
- Department of Orthopaedics, Centro Hospitalar Universitário do Porto, Porto, Portugal.,Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário do Porto and Grupo TrofaSaude, Portugal
| | - André Carvalho
- Department of Orthopaedics, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Ana Cláudia Santos
- Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário do Porto and Grupo TrofaSaude, Portugal.,Department of Microbiology, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Miguel Araújo Abreu
- Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário do Porto and Grupo TrofaSaude, Portugal.,Department of Microbiology, Centro Hospitalar Universitário do Porto, Porto, Portugal
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Abstract
Accurate diagnosis of fracture related infection (FRI) is critical for preventing poor outcomes such as loss of function or amputation. Due to the multiple variables associated with FRI, however, accurate diagnosis is challenging and complicated by a lack of standardized diagnostic criteria. Limitations with the current gold standard for diagnosis, which is routine microbiology culture, further complicate the diagnostic and management process. Efforts to optimize the process rely on a foundation of data derived from prosthetic joint infections (PJI), but differences in PJI and FRI make it clear that unique approaches for these distinct infections are required. A more concerted effort focusing on FRI has dominated more recent investigations and publications leading to a consensus definition by the American Orthopedics (AO) Foundation and the European Bone and Joint Infection Society (EBJIS). This has the potential to better standardize the diagnostic process, which will not only improve patient care but also facilitate more robust and reproducible research related to the diagnosis and management of FRI. The purpose of this review is to explore the consensus definition, describe the foundation of data supporting current FRI diagnostic techniques, and identify pathways for optimization of clinical microbiology-based strategies and data.
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14
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Dudareva M, Barrett LK, Morgenstern M, Atkins BL, Brent AJ, McNally MA. Providing an Evidence Base for Tissue Sampling and Culture Interpretation in Suspected Fracture-Related Infection. J Bone Joint Surg Am 2021; 103:977-983. [PMID: 33764925 DOI: 10.2106/jbjs.20.00409] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The recent consensus definition for the diagnosis of fracture-related infection (FRI) includes the identification of indistinguishable microorganisms in at least 2 surgical deep-tissue specimens as a confirmatory criterion. However, this cut-off, and the total number of specimens from a patient with suspected FRI that should be sent for microbiological testing, have not been validated. We endeavored to estimate the accuracy of different numbers of specimens and diagnostic cut-offs for microbiological testing of deep-tissue specimens in patients undergoing surgical treatment for possible FRI. METHODS A total of 513 surgical procedures in 385 patients with suspected FRI were included. A minimum of 2 surgical deep-tissue specimens were submitted for microbiological testing; 5 or more specimens were analyzed in 345 procedures (67%). FRI was defined by the presence of any confirmatory criteria other than microbiology. Resampling was utilized to model the sensitivity and specificity of diagnostic cut-offs for the number of surgical specimens yielding indistinguishable microorganisms and for the total number of specimens. The likelihood of detecting all clinically relevant microorganisms was also assessed. RESULTS A diagnostic cut-off of at least 2 of 5 specimens with indistinguishable microorganisms identified by culture was 68% sensitive (95% confidence interval [CI], 62% to 74%) and 87% specific (95% CI, 81% to 94%) for the diagnosis of FRI. Two out of 3 specimens were 60% sensitive (95% CI, 55% to 66%) and 92% specific (95% CI, 88% to 96%). Submitting only 3 deep-tissue specimens risked missing clinically relevant microorganisms in at least 1 in 10 cases. CONCLUSIONS The present study was the first to validate microbiological criteria for the diagnosis of FRI, supporting the current confirmatory diagnostic criteria for FRI. Analysis of at least 5 deep-tissue specimens in patients with possible FRI is recommended. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- M Dudareva
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals , Oxford , United Kingdom
| | - L K Barrett
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals , Oxford , United Kingdom
| | - M Morgenstern
- Center for Musculoskeletal Infections, Department of Orthopaedic and Trauma Surgery, University Hospital Basel , Basel , Switzerland
| | - B L Atkins
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals , Oxford , United Kingdom
| | - A J Brent
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals , Oxford , United Kingdom
| | - M A McNally
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals , Oxford , United Kingdom
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15
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Kanakaris NK, Giannoudis PV. Biofilm and its implications postfracture fixation: All I need to know. OTA Int 2021; 4:e107(1-7). [PMID: 37609478 PMCID: PMC10441677 DOI: 10.1097/oi9.0000000000000107] [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: 09/28/2020] [Revised: 11/10/2020] [Accepted: 12/11/2020] [Indexed: 08/24/2023]
Abstract
Biofilm represents an organized multicellular community of bacteria having a complex 3D structure, formed by bacterial cells and their self-produced extracellular matrix. It usually attaches to any foreign body or fixation implant. It acts as a physical protective barrier of the bacteria from the penetration of antibodies, bacteriophages, granulocytes and biocides, antiseptics, and antibiotics. Biofilm-related infections will increase in the near future. This group of surgical site infections is the most difficult to diagnose, to suppress, to eradicate, and in general to manage. Multispecialty teams involved in all stages of care are an effective way to improve results and save resources and time for the benefit of patients and the health system. Significant steps have occurred recently in the prevention and development of clever tools that we can employ in this everlasting fight with the bacteria. Herein, we attempt to describe the nature and role of the "biofilm" to the specific clinical setting of surgical site infections in the field of orthopaedic trauma surgery.
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Affiliation(s)
- Nikolaos K Kanakaris
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds
- NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, United Kingdom
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds
- NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, United Kingdom
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16
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Bellova P, Knop-Hammad V, Königshausen M, Schildhauer TA, Gessmann J, Baecker H. Sonication in the diagnosis of fracture-related infections (FRI)-a retrospective study on 230 retrieved implants. J Orthop Surg Res 2021; 16:310. [PMID: 33985549 PMCID: PMC8117644 DOI: 10.1186/s13018-021-02460-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/06/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In fracture-related infections (FRI), both the diagnosis of the infection and the identification of the causative pathogen are crucial to optimize treatment outcomes. Sonication has been successfully used for periprosthetic joint infections (PJI); however, its role in FRI remains unknown. Our aim was to determine the diagnostic accuracy (sensitivity, specificity) of sonicate fluid culture (SFC). The primary objective was to compare SFC with peri-implant tissue culture (PTC) overall and among subgroups using the consensus definition by Metsemakers et al. The secondary objective was to determine the yield of SFC in possible fracture-related infections (PFRI). METHODS From March 2017 to May 2019, 230 cases of retrieved implants were retrospectively reviewed. To perform sonication, explants were placed in sterile polypropylene jars intraoperatively. After treatment in an ultrasonic bath (Bandelin, Berlin, Germany), sonicate fluid was incubated into blood culture bottles, and conventional culturing was eventually performed. Sensitivity and specificity were determined using two-by-two contingency tables. McNemar's test was used to compare proportions among paired samples while Fisher's exact test was used for comparison between categorical variables. RESULTS Of the 230 cases, 107 were identified as FRI, whereas 123 were aseptic revision cases (ARC). Of the latter, 105 were labeled as PFRI. Sensitivity of SFC was higher in comparison with PTC, although this did not reach statistical significance (90.7% vs. 84.1%; p = .065). The specificity of SFC was significantly lower than that of PTC (73.2% vs. 88.6%; p = .003). In PFRI, SFC yielded significantly more positive results than PTC (33/105 vs. 14/105; p = .003). Overall, 142 pathogens were identified by SFC, whereas 131 pathogens were found by PTC. CONCLUSIONS We found that sonication of fracture fixation devices may be a useful adjunct in FRI, especially in "low-grade" infections lacking confirmatory clinical criteria. Standardized diagnostic protocols are warranted in order to further optimize the diagnostic accuracy.
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Affiliation(s)
- Petri Bellova
- Department of Orthopedics and Trauma Surgery, BG University Clinic Bergmannsheil Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany.
| | - Veronika Knop-Hammad
- Department of Microbiology, BG University Clinic Bergmannsheil Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Matthias Königshausen
- Department of Orthopedics and Trauma Surgery, BG University Clinic Bergmannsheil Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Thomas A Schildhauer
- Department of Orthopedics and Trauma Surgery, BG University Clinic Bergmannsheil Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Jan Gessmann
- Department of Orthopedics and Trauma Surgery, BG University Clinic Bergmannsheil Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Hinnerk Baecker
- Department of Orthopedics and Trauma Surgery, BG University Clinic Bergmannsheil Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
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Ahmed EA, Almutairi MK, Alkaseb AT. Accuracy of Tissue and Sonication Fluid Sampling for the Diagnosis of Fracture-Related Infection: Diagnostic Meta-Analysis. Cureus 2021; 13:e14925. [PMID: 34123624 PMCID: PMC8187062 DOI: 10.7759/cureus.14925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Evidence shows that tissue sample culturing is the gold standard approach for diagnosing fracture-related infection (FRI). Sonication fluid sampling has also been reported to be efficacious and superior to tissue sample culturing with prosthetic joint infection. However, data from the current literature are not enough to validate this hypothesis for FRI. We conducted a meta-analysis to validate the diagnostic accuracy of tissue sample culturing and sonication fluid aspiration and to find which one is superior to the other. An extensive search through the relevant databases was conducted to obtain all the relevant studies. We have included 13 relevant studies, including nine retrospective cohorts and four prospective ones. The overall pooled estimates of sensitivity, specificity, and diagnostic odds ratio (DOR) of tissue sampling culture in diagnosing fracture-related infections were 98% (95% CI, 92% to 99%), 38% (95% CI, 23% to 56%), and 25 (4 to 154), respectively. The overall pooled estimates of sensitivity, specificity, and DOR of sonication fluid sample culture in diagnosing fracture-related infections were 86% (95% CI, 79% to 92%), 98% (95% CI, 93% to 100%), and 353 (78 to 1598), respectively. No significant risk of bias was found regarding the sensitivity and specificity among studies investigating both modalities, however, significant heterogeneity was noticed. Sonication fluid sampling can be used to confirm FRI while tissue sampling can be used to exclude it and both modalities should be combined for obtaining the most accurate outcome.
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Affiliation(s)
- Elsiddig A Ahmed
- Department of Orthopedics and Traumatology, Prince Mutaibb bin Abdulaziz Hospital, Sakaka, SAU
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Mingo-Robinet J, Pérez Aguilar M. Implant removal of osteosynthesis. Results of a survey among Spanish orthopaedic surgeons. Rev Esp Cir Ortop Traumatol (Engl Ed) 2021. [PMID: 33926847 DOI: 10.1016/j.recot.2020.11.007] [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: 09/30/2022] Open
Abstract
INTRODUCTION The indications on extraction of osteosynthesis material are not well defined in the current literature deriving in relative indications, depending on experiences, customs or patient's request. The aim of this article is to assess the beliefs, indications, usual practice and perceived complications of surgeons in Spain regarding on extraction of osteosynthesis material. METHODS We conducted a questionnaire of 44 questions covering general demographics, general and subjective opinion on implant removal, specific attitudes by implant type and anatomical location, and personal habits. RESULTS 164 questionnaires were received. The most frequent indications are patellar and olecranon cerclage wires and elastic nails in children. 56% remove the implant at the patient's request, 31% always remove it in children, 28% do it in asymptomatic patients to avoid possible surgical problems, 14% to avoid a possible peri-implant fracture and 9% by simple preference. The most frequent intraoperative complications are surgery longer than expected, bone growth over the implant, rounded screw head core, cold fusion, difficulty in finding the implant and impossibility to remove part of the implant. The most frequent postoperative complication was persistence of symptoms 39.8%. CONCLUSION The results provide information to advise the patient regarding the expected clinical outcome and intra and postoperative complications. The surgeon should cautiously indicate extraction in the asymptomatic patient given the high rate of complications.
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Affiliation(s)
- J Mingo-Robinet
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Rio Carrión, Palencia, España.
| | - M Pérez Aguilar
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Marqués de Valdecilla, Santander, España
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Veis DJ, Cassat JE. Infectious Osteomyelitis: Marrying Bone Biology and Microbiology to Shed New Light on a Persistent Clinical Challenge. J Bone Miner Res 2021; 36:636-643. [PMID: 33740314 DOI: 10.1002/jbmr.4279] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 02/01/2021] [Accepted: 02/19/2021] [Indexed: 12/11/2022]
Abstract
Infections of bone occur in a variety of clinical settings, ranging from spontaneous isolated infections arising from presumed hematogenous spread to those associated with skin and soft tissue wounds or medical implants. The majority are caused by the ubiquitous bacterium Staphyloccocus (S.) aureus, which can exist as a commensal organism on human skin as well as an invasive pathogen, but a multitude of other microbes are also capable of establishing bone infections. While studies of clinical isolates and small animal models have advanced our understanding of the role of various pathogen and host factors in infectious osteomyelitis (iOM), many questions remain unaddressed. Thus, there are many opportunities to elucidate host-pathogen interactions that may be leveraged toward treatment or prevention of this troublesome problem. Herein, we combine perspectives from bone biology and microbiology and suggest that interdisciplinary approaches will bring new insights to the field. © 2021 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Deborah J Veis
- Division of Bone and Mineral Diseases, Departments of Medicine and Pathology, Washington University School of Medicine, St. Louis, MO, USA.,Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA.,Musculoskeletal Research Center, Washington University School of Medicine, St. Louis, MO, USA.,Shriners Hospitals for Children, St. Louis, MO, USA
| | - James E Cassat
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville,, TN, USA.,Department of Pediatrics, Division of Pediatric Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA.,Vanderbilt Institute for Infection, Immunology and Inflammation (VI4), Vanderbilt University Medical Center, Nashville, TN, USA.,Vanderbilt Center for Bone Biology, Vanderbilt University Medical Center, Nashville, TN, USA
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20
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Dudek P, Grajek A, Kowalczewski J, Madycki G, Marczak D. Ultrasound frequency of sonication applied in microbiological diagnostics has a major impact on viability of bacteria causing PJI. Int J Infect Dis 2020; 100:158-163. [PMID: 32827750 DOI: 10.1016/j.ijid.2020.08.038] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/07/2020] [Accepted: 08/16/2020] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Sonication of explanted prosthesis constitutes an element of microbiological diagnostics. The aim of performing this procedure is to remove biofilm and to increase sensitivity of diagnostics. Ultrasound used in medical purposes are low-frequency and low-intensity. With this wide range of frequency which can be used in sonication process it is necessary to find the golden mean between biofilm dislodging and planktonic bacteria sparing. MATERIALS AND METHODS The aim of this study was to determine the least harming low-intensity ultrasound frequency (35 kHz, 40 kHz or 53 kHz) used during sonication process with other parameters constant. Four bacteria species were examined: S. aureus, E. faecalis, E. coli, K. pneumoniae. Number of microbiological studies (n) for each group (g) counted 40 specimens (based on scheme 1 bacteria type - 4 groups, 40 studies each). RESULTS A detailed analysis of gathered data was conducted. Based on study findings following conclusions were drawn. Sonication has a significant and negative impact on survival of sonicated planktonic bacteria. Part of bacteria in planktonic state are damaged/killed by ultrasound, which is demonstrated by lower CFU count in sonicated samples versus control group. CONCLUSIONS Optimal ultrasound frequencies for sonication of S. aureus, P. aeruginosa and E. coli are 35 kHz and 40 kHz. Ultrasound frequencies used in sonication process (35 kHz, 40 kHz, 53 kHz) of E. coli showed same impact on bacteria survival. It is crucial to perform further assessment of ultrasound parameters on clinical effects of sonication used in PJI diagnostics.
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Affiliation(s)
- Piotr Dudek
- Centre of Postgraduate Medical Education, Department of Orthopaedics and Rheumoorthopaedics, Warsaw, Poland.
| | - Aleksandra Grajek
- Centre of Postgraduate Medical Education, Department of Laboratory Diagnostics, Otwock, Poland
| | - Jacek Kowalczewski
- Centre of Postgraduate Medical Education, Department of Orthopaedics and Rheumoorthopaedics, Warsaw, Poland
| | - Grzegorz Madycki
- Centre of Postgraduate Medical Education, Department of Vascular Surgery and Angiology, Warsaw, Poland
| | - Dariusz Marczak
- Centre of Postgraduate Medical Education, Department of Orthopaedics and Rheumoorthopaedics, Warsaw, Poland
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Microbiological diagnosis of intramedullary nailing infection: comparison of bacterial growth between tissue sampling and sonication fluid cultures. INTERNATIONAL ORTHOPAEDICS 2020; 45:565-573. [PMID: 32783073 DOI: 10.1007/s00264-020-04771-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 08/04/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Intramedullary nailing (IMN) has been frequently indicated to treat long bone open and closed fractures, but IMN infection (IMNI) may have devastating consequences. Sonication has been regarded as an important add-on for microbial identification on a variety of orthopaedic implant-associated infections, but its role in the IMNI is poorly studied. We aim at evaluating the accuracy obtained by conventional peri-implant tissue culture (TC) samples with sonication fluid cultures (SCs) of IMNI. METHODS Longitudinal prospective cohort study ongoing since June 2014, which included patients with indication for IMN removal due to any reason. Clinical diagnosis of INMI was defined according to publication addressing fracture-related infections. Minimal of two samples from TC were cultured. SCs followed the protocol previously published. Statistical analysis was performed using McNemar's test for related proportions. RESULTS We included 54 patients submitted to IMN retrieval, of whom 47 presenting clinical signs of IMNI. Sensitivity for detecting microorganisms using TC and SC was 89.4% (42/47) and 97.6% (40/41), and specificity was 71.4% (5/7) for both TC and SC (p = 1.00). Positive and negative predictive values for TC and SC were 95.5% (42/44), 95.2% (40/42), 50% (5/10), and 83.3% (5/6), respectively. The most frequent organisms isolated in both TC and SC were Staphylococcus aureus, S. epidermidis, and Enterococcus sp. Polymicrobial infection was diagnosed in 14.8% (8/54) and 25% (12/48) by TC and SC, respectively (p = 0.19). CONCLUSION Sonication fluid and tissue samples presented similar accuracy on the diagnosis of IMNI, but SC was advantageous of detecting polymicrobial infection.
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A qualitative method for testing the antimicrobial ability of osteosynthetic fixation material by simulating in vitro contamination by Staphylococcus aureus. Folia Microbiol (Praha) 2020; 65:679-686. [DOI: 10.1007/s12223-020-00774-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 01/16/2020] [Indexed: 10/25/2022]
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How to Diagnose Surgical Site Infection After Fracture Surgery: We Have a Problem! Tech Orthop 2020. [DOI: 10.1097/bto.0000000000000462] [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: 11/25/2022]
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Outcome of spinal implant-associated infections treated with or without biofilm-active antibiotics: results from a 10-year cohort study. Infection 2020; 48:559-568. [PMID: 32372396 PMCID: PMC7395063 DOI: 10.1007/s15010-020-01435-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 04/24/2020] [Indexed: 12/17/2022]
Abstract
Purpose Biofilm-active antibiotics are suggested to improve the outcome of implant-associated infections; however, their role in infections after spinal instrumentation is unclear. Therefore, we evaluated the outcome of patients with spinal implant-associated infections treated with and without biofilm-active antibiotics. Methods The probability of infection-free survival was estimated for treatment of spinal implant-associated infections with and without biofilm-active antibiotics using the Kaplan–Meier method; Cox proportional-hazards regression model was used to identify factors associated with treatment failure. Results Among 93 included patients, early-onset infection was diagnosed in 61 (66%) and late-onset in 32 infections (34%). Thirty patients (32%) were treated with biofilm-active antibiotic therapy and 63 (68%) without it. The infection-free survival after a median follow-up of 53.7 months (range, 8 days-9.4 years) was 67% (95% confidence interval [CI], 55–82%) after 1 year and 58% (95% CI 43–71%) after 2 years. The infection-free survival after 1 and 2 years was 94% (95% CI 85–99%) and 84% (95% CI 71–93%) for patients treated with biofilm-active antibiotics, respectively, and 57% (95% CI 39–80%) and 49% (95% CI 28–61%) for those treated without biofilm-active antibiotics, respectively (p = 0.009). Treatment with biofilm-active antibiotics (hazard ratio [HR], 0.23, 95% CI 0.07–0.77), infection with Staphylococcus auras (HR, 2.19, 95% CI 1.04–4.62) and polymicrobial infection (HR, 2.44, 95% CI 1.09–6.04) were significantly associated with treatment outcome. Severe pain was observed more often in patients without biofilm-active antibiotic therapy (49% vs. 18%, p = 0.027). Conclusion Treatment with biofilm-active antibiotics was associated with better treatment outcome and less postoperative pain intensity. Electronic supplementary material The online version of this article (10.1007/s15010-020-01435-2) contains supplementary material, which is available to authorized users.
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Wong RM, Li TK, Li J, Ho WT, Chow SKH, Leung SS, Cheung WH, Ip M. A systematic review on current osteosynthesis-associated infection animal fracture models. J Orthop Translat 2020; 23:8-20. [PMID: 32440511 PMCID: PMC7231979 DOI: 10.1016/j.jot.2020.03.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 02/18/2020] [Accepted: 03/02/2020] [Indexed: 02/06/2023] Open
Abstract
Objective Osteosynthesis-associated infection is a challenging complication post fracture fixation, burdening the patients and the orthopaedic surgeons alike. A clinically relevant animal model is critical in devising new therapeutic strategies. Our aim was to perform a systematic review to evaluate existing preclinical models and identify their applications in aspects of animal selection, bacterial induction, fracture fixation and complications. Methods A systematic literature research was conducted in PubMed and Embase up to February 2020. A total of 31 studies were included. Information on the animal, bacterial induction, fracture fixation, healing result and complications were extracted. Results Animals selected included murine (23), rabbit (6), ewe (1) and goat (1). Larger animals had enabled the use of human-sized implant, however small animals were more economical and easier in handling. Staphylococcus aureus (S. aureus) was the most frequently chosen bacteria for induction. Bacterial inoculation dose ranged from 102-8 CFU. Consistent and replicable infections were observed from 104 CFU in general. Methods of inoculation included injections of bacterial suspension (20), placement of foreign objects (8) and pretreatment of implants with established biofilm (3). Intramedullary implants (13), plates and screws (18) were used in most models. Radiological (29) and histological evaluations (24) in osseous healing were performed. Complications such as instability of fracture fixation (7), unexpected surgical death (5), sepsis (1) and persistent lameness (1) were encountered. Conclusion The most common animal model is the S. aureus infected open fracture internally fixated. Replicable infections were mainly from 104 CFU of bacteria. However, with the increase in antibiotic resistance, future directions should explore polymicrobial and antibiotic resistant strains, as these will no doubt play a major role in bone infection. Currently, there is also a lack of osteoporotic bone infection models and the pathophysiology is unexplored, which would be important with our aging population. The translational potential of this article This systematic review provides an updated overview and compares the currently available animal models of osteosynthesis-associated infections. A discussion on future research directions and suggestion of animal model settings were made, which is expected to advance the research in this field.
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Affiliation(s)
- Ronald M.Y. Wong
- Department of Orthopaedics and Traumatology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Tsz-kiu Li
- Department of Orthopaedics and Traumatology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Jie Li
- Department of Orthopaedics and Traumatology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Wing-Tung Ho
- Department of Orthopaedics and Traumatology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Simon K.-H. Chow
- Department of Orthopaedics and Traumatology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | | | - Wing-Hoi Cheung
- Department of Orthopaedics and Traumatology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
- Corresponding author. Department of Orthopaedics and Traumatology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong.
| | - Margaret Ip
- Department of Microbiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
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Finelli CA, Dos Reis FB, Fernandes HA, Dell'Aquila A, Carvalho R, Miki N, Franciozi C, Abdalla R, Salles MJC. Intramedullary reaming modality for management of postoperative long bone infection: a prospective randomized controlled trial in 44 patients. Patient Saf Surg 2019; 13:39. [PMID: 31827616 PMCID: PMC6889343 DOI: 10.1186/s13037-019-0215-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 10/09/2019] [Indexed: 11/10/2022] Open
Abstract
Background Studies addressing the management of intramedullary infection are mainly retrospective and with a limited number of cases. Reaming can be performed using either conventional reaming or using the reamer/irrigator/aspirator (RIA) system. Until now there have been no comparative prospective studies between these two methods. We aimed to compare the efficacy of RIA with conventional reaming followed by insertion of antibiotic-loaded cement, for the treatment of intramedullary nail infection of long bones. We assessed the rate of remission between groups after two-year follow-up and identified microorganisms using tissue cultures and sonication of explanted intramedullary nail (IMN). Methods A noninferiority, randomized clinical trial was carried out between August 2013 and August 2015 involving 44 patients of whom a locked IMN implant of the femur and/or tibia was retrieved and who all met the clinical and radiological criteria for IMN-associated osteomyelitis. Patients were randomized into two groups: RIA alone versus conventional reaming followed by antibiotic-loaded cement insertion. Both groups also underwent six-weeks of antibiotic treatment according to the results of the antibiogram. Patients were evaluated after 1, 3, 6, 12 and 24 months for radiological and clinical follow-up. Results After 24 months, the rate of infection remission was similar between the two groups, 87% in the RIA group and 95.5% in the conventional reaming group (p = 0.60). Among four patients who had recurrence of infection, the time to reappearance of symptoms varied from 20 days to twenty-two months. Staphylococcus aureus and coagulase-negative Staphylococci were isolated in 23 (40.4%) and 13 (22.9%) patients, respectively. Interestingly, we identified 20% (9/45) of polymicrobial infection. Conclusion This study concludes that the RIA system alone, is noninferior to conventional reaming followed by antibiotic cement spacer in the treatment of IMN infection. However, RIA shows greater efficacy in the collection of infected medullary bone tissue, mainly in cases of infected retrograde nail of the femur. Trial registration ISRCTN82233198. Retroactively registered on July 29, 2019.
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Affiliation(s)
- Carlos Augusto Finelli
- 1Department of Orthopedics and Traumatology, (DOT/UNIFESP), Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros 715, São Paulo, SP 04024-002 Brazil
| | - Fernando Baldy Dos Reis
- 1Department of Orthopedics and Traumatology, (DOT/UNIFESP), Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros 715, São Paulo, SP 04024-002 Brazil
| | - Helio Alvachian Fernandes
- 1Department of Orthopedics and Traumatology, (DOT/UNIFESP), Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros 715, São Paulo, SP 04024-002 Brazil
| | - Adriana Dell'Aquila
- 1Department of Orthopedics and Traumatology, (DOT/UNIFESP), Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros 715, São Paulo, SP 04024-002 Brazil
| | - Rogério Carvalho
- 1Department of Orthopedics and Traumatology, (DOT/UNIFESP), Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros 715, São Paulo, SP 04024-002 Brazil
| | - Natalia Miki
- 1Department of Orthopedics and Traumatology, (DOT/UNIFESP), Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros 715, São Paulo, SP 04024-002 Brazil
| | - Carlos Franciozi
- 1Department of Orthopedics and Traumatology, (DOT/UNIFESP), Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros 715, São Paulo, SP 04024-002 Brazil
| | - Rene Abdalla
- 1Department of Orthopedics and Traumatology, (DOT/UNIFESP), Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros 715, São Paulo, SP 04024-002 Brazil
| | - Mauro José Costa Salles
- 1Department of Orthopedics and Traumatology, (DOT/UNIFESP), Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros 715, São Paulo, SP 04024-002 Brazil.,2Santa Casa de São Paulo School of Medical Sciences, São Paulo, SP Brazil
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Jiang N, Wang BW, Chai YM, Wu XB, Tang PF, Zhang YZ, Yu B. Chinese expert consensus on diagnosis and treatment of infection after fracture fixation. Injury 2019; 50:1952-1958. [PMID: 31445830 DOI: 10.1016/j.injury.2019.08.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Currently, accurate diagnosis and successful treatment of infection after fracture fixation (IAFF) still impose great challenges. According to the onset of infection symptoms after implantation, IAFF is classified as early infection (<2 weeks), delayed infection (2∼10 weeks) and late infection (>10 weeks). Confirmation of IAFF should be supported by histopathological tests of intraoperative specimens which confirm infection, cultures from at least two suspected infection sites which reveal the same pathogen, a definite sinus or fistula which connects directly the bone or the implant, and purulent drainage from the wound or presence of pus during surgery. Diagnosis of IAFF is built on comprehensive assessment of medical history, clinical signs and symptoms of the patient, and imaging and laboratory tests. The gold standard of diagnosis is histopathological tests. Treatment of IAFF consists of radical debridement, adequate irrigation, implant handling, systematic and local antibiotics, reconstruction of osseous and/or soft tissue defects, and functional rehabilitation of an affected limb. Early accurate diagnosis and appropriate treatment of IAFF play a key role in increasing the cure rate, reducing infection recurrence and disability risk, restoring limb function and improving quality of life of the patient.
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Affiliation(s)
- Nan Jiang
- Department of Orthopaedics & Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Bo-Wei Wang
- Department of Orthopaedics & Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Yi-Min Chai
- Department of Orthopaedics, The Sixth People's Hospital of Shanghai Jiao Tong University, Shanghai, PR China
| | - Xin-Bao Wu
- Department of Orthopaedics & Traumatology, Beijing Jishuitan Hospital, Beijing, PR China.
| | - Pei-Fu Tang
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, PR China.
| | - Ying-Ze Zhang
- Department of Orthopaedics, The Third Hospital of Hebei Medical University, Shijiazhuang, PR China.
| | - Bin Yu
- Department of Orthopaedics & Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China.
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Abstract
Infection can be a devastating complication of surgically inserted prosthetic implants and intramedullary rods, plates and pins. About 2 million implants were inserted in the United States in 2004, and, despite appropriate perioperative antibiotics, approximately 5% of internal fixation devices became infected. Infection rates in fractures that pierce the skin can be as high as 22.7%. Complications of infection include excessive antibiotic use, implant removal, reoperation, and potential amputation. Infections caused by colonized prosthetic implants are often difficult to predict, diagnose, and treat, because they form biofilms. This article explores the approach to infected implants.
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Affiliation(s)
- Dena El-Sayed
- Internal Medicine Clinic, Infectious Diseases Clinic, Ventura County Medical Center, Ventura, CA, USA
| | - Aksone Nouvong
- Department of Surgery, Division of Vascular Surgery, David Geffen School of Medicine at UCLA, 200 Medical Plaza, Suite 526, Los Angeles, CA 90095, USA.
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Pathogenesis and management of fracture-related infection. Clin Microbiol Infect 2019; 26:572-578. [PMID: 31446152 DOI: 10.1016/j.cmi.2019.08.006] [Citation(s) in RCA: 112] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 08/09/2019] [Accepted: 08/10/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Both fracture-related infections (FRIs) and periprosthetic joint infections (PJIs) include orthopaedic implant-associated infections. However, key aspects of management differ due to the bone and soft tissue damage in FRIs and the option of removing the implant after fracture healing. In contrast to PJIs, research and guidelines for diagnosis and treatment in FRIs are scarce. OBJECTIVES This narrative review aims to update clinical microbiologists, infectious disease specialists and surgeons on the management of FRIs. SOURCES A computerized search of PubMed was performed to identify relevant studies. Search terms included 'Fracture' and 'Infection'. The reference lists of all retrieved articles were checked for additional relevant references. In addition, when scientific evidence was lacking, recommendations are based on expert opinion. CONTENT Pathogenesis, prevention, diagnosis and treatment of FRIs are presented. Whenever available, specific data of patients with FRI are discussed. IMPLICATIONS Management of patients with FRI should take into account FRI-specific features. Treatment pathways should implement a multidisciplinary approach to achieve a good outcome. Recently, international consensus guidelines were developed to improve the quality of care for patients suffering from this severe complication, which are highlighted in this review.
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Abstract
Infection after fracture fixation is a feared complication in orthopaedic surgery leading to poor bone healing and loss of function.Early detection is essential and interdisciplinary care is mandatory.Eradication of infection is only possible through combined surgical and antibiotic treatment.Intraoperative tissue samples must be taken and are effective for guidance of the antibiotic regimen.Infection after fracture fixation is different from prosthetic joint infection (PJI) and needs a specific strategy.In this review, we define infection after fracture fixation, and outline the clinical, radiological and laboratory signs of these infections, as well as a treatment algorithm for optimal patient care. Cite this article: EFORT Open Rev 2019;4:468-475. DOI: 10.1302/2058-5241.4.180093.
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Affiliation(s)
- Sylvain Steinmetz
- Service of Orthopaedics and Traumatology, Lausanne University Hospital, Lausanne, Switzerland
| | - Diane Wernly
- Service of Orthopaedics and Traumatology, Lausanne University Hospital, Lausanne, Switzerland
| | - Kevin Moerenhout
- Service of Orthopaedics and Traumatology, Lausanne University Hospital, Lausanne, Switzerland
| | - Andrej Trampuz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Olivier Borens
- Service of Orthopaedics and Traumatology, Lausanne University Hospital, Lausanne, Switzerland
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Ellington K, Raikin S, Bemenderfer TB. What Strategies Can Be Implemented to Help Isolate the Causative Organism in Patients With Infection of the Foot and Ankle? Foot Ankle Int 2019; 40:33S-38S. [PMID: 31322940 DOI: 10.1177/1071100719859887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
RECOMMENDATION Transfer of synovial aspirate in blood culture bottles, obtaining deep biopsy of tissues and bone, obtaining multiple samples, increasing incubation period of cultures, and the use of molecular techniques for culture negative cases are some of the strategies that can help improve the ability to isolate the causative organism(s) in infections of foot and ankle. LEVEL OF EVIDENCE Moderate. DELEGATE VOTE Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).
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Affiliation(s)
- Kent Ellington
- 1 OrthoCarolina, Foot and Ankle Institute, AtriumHealth, Charlotte, NC, USA
| | - Steven Raikin
- 2 Sydney Kimmel Medical College, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Drago L, Clerici P, Morelli I, Ashok J, Benzakour T, Bozhkova S, Alizadeh C, Del Sel H, Sharma HK, Peel T, Mattina R, Romanò CL. The World Association against Infection in Orthopaedics and Trauma (WAIOT) procedures for Microbiological Sampling and Processing for Periprosthetic Joint Infections (PJIs) and other Implant-Related Infections. J Clin Med 2019; 8:E933. [PMID: 31261744 PMCID: PMC6678965 DOI: 10.3390/jcm8070933] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 06/18/2019] [Accepted: 06/26/2019] [Indexed: 12/12/2022] Open
Abstract
While implant-related infections continue to play a relevant role in failure of implantable biomaterials in orthopaedic and trauma there is a lack of standardised microbiological procedures to identify the pathogen(s). The microbiological diagnosis of implant-related infections is challenging due to the following factors: the presence of bacterial biofilm(s), often associated with slow-growing microorganisms, low bacterial loads, previous antibiotic treatments and, possible intra-operative contamination. Therefore, diagnosis requires a specific set of procedures. Based on the Guidelines of the Italian Association of the Clinical Microbiologists (AMCLI), the World Association against Infection in Orthopaedics and Trauma has drafted the present document. This document includes guidance on the basic principles for sampling and processing for implant-related infections based on the most relevant literature. These procedures outline the main microbiological approaches, including sampling and processing methodologies for diagnostic assessment and confirmation of implant-related infections. Biofilm dislodgement techniques, incubation time and the role of molecular approaches are addressed in specific sections. The aim of this paper is to ensure a standardised approach to the main microbiological methods for implant-related infections, as well as to promote multidisciplinary collaboration between clinicians and microbiologists.
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Affiliation(s)
- Lorenzo Drago
- Clinical Microbiology, Department of Biomedical Sciences for Health, University of Milan, 20100 Milano, Italy.
| | - Pierangelo Clerici
- Laboratory of Clinical Microbiology, AO Legnano Hospital, AMCLI, 20025 Milano, Italy.
| | - Ilaria Morelli
- Residency Program in Orthopaedics and Traumatology, University of Milan, 20100 Milano, Italy.
| | - Johari Ashok
- Department of Paediatric Orthopaedics and Spine Surgery, Children's Orthopedic Centre, Mumbai 230532, India.
| | | | - Svetlana Bozhkova
- Department of Prevention and Treatment of Wound Infection, R.R. Vreden Russian Research Institute of Traumatology and Orthopaedics, 33701 S. Petersburg, Russia.
| | - Chingiz Alizadeh
- Traumatology & Orthopedics Department, Baku Health Clinic, 1005 Baku, Azerbaijian.
| | - Hernán Del Sel
- Department of Orthopaedics, British Hospital Buenos Aires, Buenos Aires B1675, Argentina.
| | - Hemant K Sharma
- Hull University Teaching Hospitals, Anlaby Road, Hull HU3 2JZ, UK.
| | - Trisha Peel
- Department of Infectious Diseases, Monash University, Melbourne, VIC 3004, Australia.
| | - Roberto Mattina
- Department of Odontoiatric and Surgical Sciences, University of Milan, 20100 Milano, Italy.
| | - Carlo Luca Romanò
- Studio Medico Cecca-Romanò, corso Venezia, 2, 20121 Milano, Italy.
- Romano Institute, Rruga Ibrahim Rugova, 1001 Tirane, Albania.
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Ueda N, Oe K, Nakamura T, Tsuta K, Iida H, Saito T. Sonication of Extracted Implants Improves Microbial Detection in Patients With Orthopedic Implant-Associated Infections. J Arthroplasty 2019; 34:1189-1196. [PMID: 30872034 DOI: 10.1016/j.arth.2019.02.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 02/12/2019] [Accepted: 02/13/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND We assessed whether combining the conventional culture and implant sonicate fluid culture (SFC) methods increased the diagnostic accuracy of orthopedic implant-associated infection (OIAI). METHODS Consecutive patients (n = 66) undergoing implant removal (OIAI, 17; non-OIAI, 49) were evaluated prospectively. We analyzed 493 samples (39 preoperative joint aspirates, 243 peri-implant tissue specimens, 124 implant sonication, 67 controls, and 20 water bath samples). OIAI was preoperatively evaluated based on clinical evidence of infection or aspirate culture (AC). Conventional methods required positive results in either preoperative ACs or intraoperative tissue cultures (TCs), whereas the combination method required at least 1 positive culture among 3 sources (AC, TC, or SFC). The application of SFC and the detection rate, sensitivity, and specificity of the diagnostic methods were assessed. RESULTS No controls or water bath samples harbored bacteria. Three patients (18%) were detected by SFC only and Peptostreptococcus and Corynebacterium species were isolated by SFC only. The OIAI detection rate attributable to SFC was significantly higher than that of TC (61% vs 36%; P = .02). The sensitivities of AC, TC, and SFC at a cutoff point of 1 colony-forming unit/plate and 1 positive culture were 60%, 59%, and 71%, respectively. At a cutoff point of 2 positive cultures, the combination (vs conventional) method showed significantly greater sensitivity (71% vs 47%; P = .008). CONCLUSION By incorporating SFCs into conventional culture methods, the diagnostic accuracy in the context of OIAI was significantly improved.
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Affiliation(s)
- Narumi Ueda
- Department of Orthopedic Surgery, Kansai Medical University Medical Center, Moriguchi, Osaka, Japan
| | - Kenichi Oe
- Department of Orthopedic Surgery, Kansai Medical University, Hirakata, Osaka, Japan
| | - Tomohisa Nakamura
- Department of Orthopedic Surgery, Kansai Medical University, Hirakata, Osaka, Japan
| | - Koji Tsuta
- Department of Clinical Laboratory, Kansai Medical University, Hirakata, Osaka, Japan
| | - Hirokazu Iida
- Department of Orthopedic Surgery, Kansai Medical University Medical Center, Moriguchi, Osaka, Japan
| | - Takanori Saito
- Department of Orthopedic Surgery, Kansai Medical University, Hirakata, Osaka, Japan
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Knabl L, Kuppelwieser B, Mayr A, Posch W, Lackner M, Coraҫa-Huber D, Danita A, Blauth M, Lass-Flörl C, Orth-Höller D. High percentage of microbial colonization of osteosynthesis material in clinically unremarkable patients. Microbiologyopen 2018; 8:e00658. [PMID: 30508282 PMCID: PMC6436426 DOI: 10.1002/mbo3.658] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 04/20/2018] [Accepted: 04/23/2018] [Indexed: 01/03/2023] Open
Abstract
Stabilization of fractures with internal fixation devices is a common procedure and implant‐associated infections are a dreaded complication. The exact pathomechanism is not completely understood; however, microbial colonization of osteosynthesis material is considered a trigger for infection. This study aimed to determine the colonization rate of osteosynthesis implants in patients with no clinical or laboratory signs of infection, using two methods, conventional culture and polymerase chain reaction (PCR) of sonication fluid. Fifty‐seven patients aged between 18 and 79 years without signs of infection who underwent routine removal of osteosynthesis devices between March 2015 and May 2017 were included in this study. Osteosynthesis material was investigated by sonication followed by cultivation of the sonication fluid in blood culture bottles and PCR analysis, simultaneously. Additionally, electron scanning microscopy was performed in nine representative implants to evaluate biofilm production. Thirty‐two (56.1%) implants showed a positive result either by culture or PCR with coagulase‐negative staphylococci being the most commonly identified microorganism (68.1%). Furthermore, the detection rate of the culture (50.9%) was significantly higher compared to PCR (21.1%). The scanning electron microscopy imaging demonstrated biofilm‐like structures in four of six culture and/or PCR‐positive samples. This study is the first, to the best of our knowledge, to demonstrate bacterial colonization of osteosynthesis implants in healthy patients with no clinical or laboratory signs of infection. Colonization rate was unexpectedly high and conventional culture was superior to PCR in microbial detection. The common understanding that colonization is a trigger for infection underlines the need for strategies to prevent colonization of implant material like antibiotic‐loaded coating or intraoperative gel application.
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Affiliation(s)
- Ludwig Knabl
- Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Bettina Kuppelwieser
- Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Astrid Mayr
- Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Wilfried Posch
- Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michaela Lackner
- Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Débora Coraҫa-Huber
- Department of Orthopedic Surgery, Experimental Orthopedics, Medical University of Innsbruck, Innsbruck, Austria
| | - Adrian Danita
- Department for Trauma Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Blauth
- Department for Trauma Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Cornelia Lass-Flörl
- Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Dorothea Orth-Höller
- Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
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Improving the Diagnosis of Orthopedic Implant-Associated Infections: Optimizing the Use of Tools Already in the Box. J Clin Microbiol 2018; 56:JCM.01379-18. [PMID: 30333127 DOI: 10.1128/jcm.01379-18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 09/28/2018] [Indexed: 11/20/2022] Open
Abstract
With the increasing number of prosthetic joints replaced annually worldwide, orthopedic implant-associated infections (OIAI) present a considerable burden. Accurate diagnostics are required to optimize surgical and antimicrobial therapy. Sonication fluid cultures have been shown in multiple studies to improve the microbiological yield of OIAIs, but uptake of sonication has not been widespread in many routine clinical microbiology laboratories. In this issue, M. Dudareva and colleagues (J Clin Microbiol 56:e00688-18, 2018, https://doi.org/10.1128/JCM.00688-18) describe their unit's experience with OIAI diagnosis using periprosthetic tissue inoculated into an automated blood culture system and sonication fluid culture.
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36
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Sonication versus Tissue Sampling for Diagnosis of Prosthetic Joint and Other Orthopedic Device-Related Infections. J Clin Microbiol 2018; 56:JCM.00688-18. [PMID: 30209185 DOI: 10.1128/jcm.00688-18] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 08/21/2018] [Indexed: 01/21/2023] Open
Abstract
Current guidelines recommend collection of multiple tissue samples for diagnosis of prosthetic joint infections (PJI). Sonication of explanted devices has been proposed as a potentially simpler alternative; however, reported microbiological yield varies. We evaluated sonication for diagnosis of PJI and other orthopedic device-related infections (DRI) at the Oxford Bone Infection Unit between October 2012 and August 2016. We compared the performance of paired tissue and sonication cultures against a "gold standard" of published clinical and composite clinical and microbiological definitions of infection. We analyzed explanted devices and a median of five tissue specimens from 505 procedures. Among clinically infected cases the sensitivity of tissue and sonication culture was 69% (95% confidence interval, 63 to 75) and 57% (50 to 63), respectively (P < 0.0001). Tissue culture was more sensitive than sonication for both PJI and other DRI, irrespective of the infection definition used. Tissue culture yield was higher for all subgroups except less virulent infections, among which tissue and sonication culture yield were similar. The combined sensitivity of tissue and sonication culture was 76% (70 to 81) and increased with the number of tissue specimens obtained. Tissue culture specificity was 97% (94 to 99), compared with 94% (90 to 97) for sonication (P = 0.052) and 93% (89 to 96) for the two methods combined. Tissue culture is more sensitive and may be more specific than sonication for diagnosis of orthopedic DRI in our setting. Variable methodology and case mix may explain reported differences between centers in the relative yield of tissue and sonication culture. Culture yield was highest for both methods combined.
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Gomes A, van Oosten M, Bijker KLB, Boiten KE, Salomon EN, Rosema S, Rossen JWA, Natour E, Douglas YL, Kampinga GA, van Assen S, Sinha B. Sonication of heart valves detects more bacteria in infective endocarditis. Sci Rep 2018; 8:12967. [PMID: 30154489 PMCID: PMC6113321 DOI: 10.1038/s41598-018-31029-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 08/10/2018] [Indexed: 11/09/2022] Open
Abstract
Optimal antimicrobial treatment of infective endocarditis requires identification and susceptibility patterns of pathogens. Sonication of explanted heart valves could increase the identification and culture of pathogens, as shown in prosthetic joint and pacemaker/ICD infections. We tested 26 explanted heart valves from 20 patients with active definite endocarditis for added diagnostic value of sonication to the standard microbiological workup in a prospective diagnostic proof of concept study. Two sonication protocols (broth enrichment vs. centrifugation) were compared in an additional 35 negative control valves for contamination rates. We selected sonication/centrifugation based on acceptable false positive rates (11.4%; 4/35). Sonication/enrichment yielded many false positive results in negative controls (28.6%; 10/35), mainly Propionibacterium acnes (next-generation sequencing excluded technical problems). Compared to direct culture only, adding sonication/centrifugation (including molecular testing) significantly increased the diagnostic yield from 6/26 to 17/26 valves (p = 0.003). Most importantly, culture positives almost doubled (from 6 to 10), providing unique quantitative information about antimicrobial susceptibility. Even if direct molecular testing was added to the standard workup, sonication/centrifugation provided additional diagnostic information in a significant number of valves (8/26; 31%; p = 0.013). We concluded that sonication/centrifugation added relevant diagnostic information in the workup of heart valves with infective endocarditis, with acceptable contamination rates.
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Affiliation(s)
- Anna Gomes
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Marleen van Oosten
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Kasper L B Bijker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Kathleen E Boiten
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Elisa N Salomon
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Sigrid Rosema
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - John W A Rossen
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ehsan Natour
- Department of Thoracic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Yvonne L Douglas
- Department of Cardio-Thoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Greetje A Kampinga
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Sander van Assen
- Department of Internal Medicine (Infectious Diseases), Treant Zorggroep, Hoogeveen, The Netherlands
| | - Bhanu Sinha
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Onsea J, Depypere M, Govaert G, Kuehl R, Vandendriessche T, Morgenstern M, McNally M, Trampuz A, Metsemakers WJ. Accuracy of Tissue and Sonication Fluid Sampling for the Diagnosis of Fracture-Related Infection: A Systematic Review and Critical Appraisal. J Bone Jt Infect 2018; 3:173-181. [PMID: 30155402 PMCID: PMC6098816 DOI: 10.7150/jbji.27840] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 08/01/2018] [Indexed: 12/19/2022] Open
Abstract
Introduction: Intraoperatively obtained peri-implant tissue cultures remain the standard for diagnosis of fracture-related infection (FRI), although culture-negative cases may complicate treatment decisions. This paper reviews the evidence on sonication fluid and tissue sampling for the diagnosis of FRI. Methods: A comprehensive search in Pubmed, Embase and Web-of-Science was carried out on April 5, 2018, to identify diagnostic validation studies regarding sonication fluid and tissue sampling for FRI. Results: Out of 2624 studies, nine fulfilled the predefined inclusion criteria. Five studies focused on sonication fluid culture, two on PCR and two on histopathology. One additional histopathology study was found after screening of reference lists. There is limited evidence that sonication fluid culture may be a useful adjunct to conventional tissue culture, but no strong evidence that it is superior or can replace tissue culture. Regarding molecular techniques and histopathology the evidence is even less clear. Overall, studies had variable 'gold standard' criteria for comparison and poorly reported culture methods. Conclusions: Scientific evidence on sonication fluid and tissue sampling, including culture, molecular techniques and histopathology for the diagnosis of FRI is scarce. It is imperative that laboratory protocols become standardized and uniform diagnostic criteria, as recently published in a consensus definition, be implemented.
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Affiliation(s)
- Jolien Onsea
- Department of Trauma Surgery, University Hospitals Leuven, Belgium
| | - Melissa Depypere
- Department of Laboratory Medicine, University Hospitals Leuven, Belgium
| | - Geertje Govaert
- Department of Trauma Surgery, University Medical Center Utrecht, The Netherlands
| | - Richard Kuehl
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Basel, Switzerland
| | | | - Mario Morgenstern
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland
| | - Martin McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Andrej Trampuz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery
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Morgenstern M, Kühl R, Eckardt H, Acklin Y, Stanic B, Garcia M, Baumhoer D, Metsemakers WJ. Diagnostic challenges and future perspectives in fracture-related infection. Injury 2018; 49 Suppl 1:S83-S90. [PMID: 29929701 DOI: 10.1016/s0020-1383(18)30310-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Fracture-related infection (FRI) is one of the most challenging complications in orthopaedic trauma surgery. It has severe consequences for patients and an important socio-economic impact. FRI has distinct properties and needs to be addressed interdisciplinary. Since criteria for the diagnosis of FRI are not standardized, an expert panel recently proposed a definition for FRI. In this review the current diagnostic modalities and an interdisciplinary diagnostic algorithm based on this recently published definition, are presented and future diagnostic techniques discussed. Since to date, there is no single universal diagnostic test available that gives the clinician the definitive diagnosis of FRI, it is mandatory to follow a standardized diagnostic algorithm to correctly diagnose FRI.
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Affiliation(s)
- Mario Morgenstern
- Department of Orthopedic Surgery and Traumatology, University Hospital Basel, Switzerland.
| | - Richard Kühl
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Switzerland
| | - Henrik Eckardt
- Department of Orthopedic Surgery and Traumatology, University Hospital Basel, Switzerland
| | - Yves Acklin
- Department of Orthopedic Surgery and Traumatology, University Hospital Basel, Switzerland
| | - Barbara Stanic
- Musculoskeletal Infection Group, AO Research Institute Davos, Switzerland
| | | | - Daniel Baumhoer
- Bone Tumour Reference Centre at the Institute of Pathology, University Hospital and University of Basel, Switzerland
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Comparison of Diagnostic Accuracy of Periprosthetic Tissue Culture in Blood Culture Bottles to That of Prosthesis Sonication Fluid Culture for Diagnosis of Prosthetic Joint Infection (PJI) by Use of Bayesian Latent Class Modeling and IDSA PJI Criteria for Classification. J Clin Microbiol 2018; 56:JCM.00319-18. [PMID: 29643202 DOI: 10.1128/jcm.00319-18] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 04/02/2018] [Indexed: 01/28/2023] Open
Abstract
We have previously demonstrated that culturing periprosthetic tissue in blood culture bottles (BCBs) improves sensitivity compared to conventional agar and broth culture methods for diagnosis of prosthetic joint infection (PJI). We have also shown that prosthesis sonication culture improves sensitivity compared to periprosthetic tissue culture using conventional agar and broth methods. The purpose of this study was to compare the diagnostic accuracy of tissue culture in BCBs (subsequently referred to as tissue culture) to prosthesis sonication culture (subsequently referred to as sonicate fluid culture). We studied 229 subjects who underwent arthroplasty revision or resection surgery between March 2016 and October 2017 at Mayo Clinic in Rochester, Minnesota. Using the Infectious Diseases Society of America (IDSA) PJI diagnostic criteria (omitting culture criteria) as the gold standard, the sensitivity of tissue culture was similar to that of the sonicate fluid culture (66.4% versus 73.1%, P = 0.07) but was significantly lower than that of the two tests combined (66.4% versus 76.9%, P < 0.001). Using Bayesian latent class modeling, which assumes no gold standard for PJI diagnosis, the sensitivity of tissue culture was slightly lower than that of sonicate fluid culture (86.3% versus 88.7%) and much lower than that of the two tests combined (86.3% versus 99.1%). In conclusion, tissue culture in BCBs reached sensitivity similar to that of prosthesis sonicate fluid culture for diagnosis of PJI, but the two tests combined had the highest sensitivity without compromising specificity. The combination of tissue culture in BCBs and sonicate fluid culture is recommended to achieve the highest level of microbiological diagnosis of PJI.
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Time-dependent differences in management and microbiology of orthopaedic internal fixation-associated infections: an observational prospective study with 229 patients. Clin Microbiol Infect 2018; 25:76-81. [PMID: 29649599 DOI: 10.1016/j.cmi.2018.03.040] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 03/07/2018] [Accepted: 03/28/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Little information has been published on orthopaedic internal fixation-associated infections. We aimed to analyse time-dependent microbiology, treatment, and outcome. METHODS Over a 10-year period, all consecutive patients with internal fixation-associated infections at the University Hospital of Basel, were prospectively followed and clinical, microbiological and outcome data were acquired. Infections were classified as early (0-2 weeks after implantation), delayed (3-10 weeks), and late (>10 weeks). RESULTS Two hundred and twenty-nine patients were included, with a median follow-up of 773 days (IQR 334-1400). Staphylococcus aureus was the most prevalent pathogen (in 96/229 patients, 41.9%). Enterobacteriaceae were frequent in early infections (13/49, 26.5%), whereas coagulase-negative staphylococci (36/92, 39.1%), anaerobes (15/92, 16.3%) and streptococci (10/92, 10.9%) increased in late revisions. Failure was observed in 27/229 (11.7%). Implants were retained in 42/49 (85.7%) in early, in 51/88 (57.9%) in delayed, and in 9/92 (9.8%) in late revisions (p < 0.01). Early revisions failed in 6/49 (12.2%), delayed in 9/88 (10.2%), and late in 11/92 (13.0%) (p 0.81). Debridement and retention failed in 6/42 (14.3%) for early, in 6/51 (11.8%) for delayed, and in 3/9 (33.3%) for late revisions (p 0.21). Biofilm-active antibiotic therapy tailored to resistance correlated with improved outcome for late revisions failure (6/72, 7.7% versus 6/12, 50.0%; p < 0.01) but not for early revisions failure (5/38, 13.2% versus 1/11, 9.1%; p 1.0). CONCLUSIONS Treatment of internal fixation-associated infections showed a high success rate of 87-90% over all time periods. Implant retention was highly successful in early and delayed infections but only limited in late infections.
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Renz N, Cabric S, Morgenstern C, Schuetz MA, Trampuz A. Value of PCR in sonication fluid for the diagnosis of orthopedic hardware-associated infections: Has the molecular era arrived? Injury 2018; 49:806-811. [PMID: 29486892 DOI: 10.1016/j.injury.2018.02.018] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 02/17/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Bone healing disturbance following fracture fixation represents a continuing challenge. We evaluated a novel fully automated polymerase chain reaction (PCR) assay using sonication fluid from retrieved orthopedic hardware to diagnose infection. PATIENTS AND METHODS In this prospective diagnostic cohort study, explanted orthopedic hardware materials from consecutive patients were investigated by sonication and the resulting sonication fluid was analyzed by culture (standard procedure) and multiplex PCR (investigational procedure). Hardware-associated infection was defined as visible purulence, presence of a sinus tract, implant on view, inflammation in peri-implant tissue or positive culture. McNemar's chi-squared test was used to compare the performance of diagnostic tests. For the clinical performance all pathogens were considered, whereas for analytical performance only microorganisms were considered for which primers are included in the PCR assay. RESULTS Among 51 patients, hardware-associated infection was diagnosed in 38 cases (75%) and non-infectious causes in 13 patients (25%). The sensitivity for diagnosing infection was 66% for peri-implant tissue culture, 84% for sonication fluid culture, 71% (clinical performance) and 77% (analytical performance) for sonication fluid PCR, the specificity of all tests was >90%. The analytical sensitivity of PCR was higher for gram-negative bacilli (100%), coagulase-negative staphylococci (89%) and Staphylococcus aureus (75%) than for Cutibacterium (formerly Propionibacterium) acnes (57%), enterococci (50%) and Candida spp. (25%). CONCLUSION The performance of sonication fluid PCR for diagnosis of orthopedic hardware-associated infection was comparable to culture tests. The additional advantage of PCR was short processing time (<5 h) and fully automated procedure. With further improvement of the performance, PCR has the potential to complement conventional cultures.
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Affiliation(s)
- Nora Renz
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany.
| | - Sabrina Cabric
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany; Berlin-Brandenburg Center for Regenerative Therapies, Berlin, Germany
| | - Christian Morgenstern
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Michael A Schuetz
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Andrej Trampuz
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany; Berlin-Brandenburg Center for Regenerative Therapies, Berlin, Germany
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Metsemakers WJ, Kuehl R, Moriarty TF, Richards RG, Verhofstad MHJ, Borens O, Kates S, Morgenstern M. Infection after fracture fixation: Current surgical and microbiological concepts. Injury 2018; 49:511-522. [PMID: 27639601 DOI: 10.1016/j.injury.2016.09.019] [Citation(s) in RCA: 287] [Impact Index Per Article: 47.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 09/08/2016] [Indexed: 02/02/2023]
Abstract
One of the most challenging complications in trauma surgery is infection after fracture fixation (IAFF). IAFF may result in permanent functional loss or even amputation of the affected limb in patients who may otherwise be expected to achieve complete, uneventful healing. Over the past decades, the problem of implant related bone infections has garnered increasing attention both in the clinical as well as preclinical arenas; however this has primarily been focused upon prosthetic joint infection (PJI), rather than on IAFF. Although IAFF shares many similarities with PJI, there are numerous critical differences in many facets including prevention, diagnosis and treatment. Admittedly, extrapolating data from PJI research to IAFF has been of value to the trauma surgeon, but we should also be aware of the unique challenges posed by IAFF that may not be accounted for in the PJI literature. This review summarizes the clinical approaches towards the diagnosis and treatment of IAFF with an emphasis on the unique aspects of fracture care that distinguish IAFF from PJI. Finally, recent developments in anti-infective technologies that may be particularly suitable or applicable for trauma patients in the future will be briefly discussed.
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Affiliation(s)
- W J Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Belgium.
| | - R Kuehl
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Basel, Switzerland
| | | | | | - M H J Verhofstad
- Department of Trauma Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands, The Netherlands
| | - O Borens
- Orthopedic Septic Surgical Unit, Department of the Locomotor Apparatus and Department of Surgery and Anaesthesiology, Lausanne University Hospital, Lausanne, Switzerland
| | - S Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, USA
| | - M Morgenstern
- Department of Orthopaedic and Trauma Surgery, University Hospital of Basel, Switzerland
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Jorge LS, Fucuta PS, Oliveira MGL, Nakazone MA, de Matos JA, Chueire AG, Salles MJC. Outcomes and Risk Factors for Polymicrobial Posttraumatic Osteomyelitis. J Bone Jt Infect 2018; 3:20-26. [PMID: 29545992 PMCID: PMC5852844 DOI: 10.7150/jbji.22566] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 02/03/2018] [Indexed: 11/05/2022] Open
Abstract
Background: We hypothesized that polymicrobial posttraumatic osteomyelitis (PTO) may be associated with worse outcomes when compared to monomicrobial PTO. We therefore attempted to show the outcomes and predisposing factors associated with polymicrobial PTO. Methods: A single-center case-control study was carried out from 2007 to 2012. The outcome variables analyzed were: the need for additional surgical and antibiotic treatments, rates of amputation, and mortality associated with the infection. Univariate and multivariable analyses using multiple logistic regression were performed to identify risk factors associated with polymicrobial PTO, and p < 0.05 was considered significant. Results: Among the 193 patients identified, polymicrobial PTO was diagnosed in 37.8%, and was significantly associated with supplementary surgical debridement (56.1% vs. 31%; p < 0.01), a higher consumption of antibiotics, and more amputations (6.5% vs 1.3%; p < 0.01). Factors associated with polymicrobial PTO in the multivariable analysis were older age (odds ratio [OR] = 1.02, 95% confidence interval [CI] = 1.01 to 1.03, p = 0.04), working in agriculture (OR = 2.86, 95% CI = 1.05 to 7.79, p = 0.04), open fracture Gustilo type III (OR = 2.38, 95% CI = 1.02 to 5.56, p = 0.04), need for blood transfusion (OR = 2.15, 95% CI = 1.07 to 4.32, p = 0.03), and need for supplementary debridement (OR = 2.58, 95% CI = 1.29 to 5.16, p = 0.01). Conclusions: PTO is polymicrobial in more than one-third of patients, associated with extra surgical and clinical treatment, and worse outcomes including higher rates of amputation.
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Affiliation(s)
- Luciana Souza Jorge
- Hospital de Base, Infection Control Unit, São José do Rio Preto Medical School, São Paulo, Brazil
| | - Patrícia Silva Fucuta
- Hospital de Base, Infection Control Unit, São José do Rio Preto Medical School, São Paulo, Brazil
| | | | | | | | - Alceu Gomes Chueire
- Orthopedics and Traumatology Unit, São José do Rio Preto Medical School, São Paulo, Brazil
| | - Mauro José Costa Salles
- Division of Infectious Diseases, Department of Internal Medicine; Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
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Sabaté Brescó M, Harris LG, Thompson K, Stanic B, Morgenstern M, O'Mahony L, Richards RG, Moriarty TF. Pathogenic Mechanisms and Host Interactions in Staphylococcus epidermidis Device-Related Infection. Front Microbiol 2017; 8:1401. [PMID: 28824556 PMCID: PMC5539136 DOI: 10.3389/fmicb.2017.01401] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 07/11/2017] [Indexed: 12/25/2022] Open
Abstract
Staphylococcus epidermidis is a permanent member of the normal human microbiota, commonly found on skin and mucous membranes. By adhering to tissue surface moieties of the host via specific adhesins, S. epidermidis is capable of establishing a lifelong commensal relationship with humans that begins early in life. In its role as a commensal organism, S. epidermidis is thought to provide benefits to human host, including out-competing more virulent pathogens. However, largely due to its capacity to form biofilm on implanted foreign bodies, S. epidermidis has emerged as an important opportunistic pathogen in patients receiving medical devices. S. epidermidis causes approximately 20% of all orthopedic device-related infections (ODRIs), increasing up to 50% in late-developing infections. Despite this prevalence, it remains underrepresented in the scientific literature, in particular lagging behind the study of the S. aureus. This review aims to provide an overview of the interactions of S. epidermidis with the human host, both as a commensal and as a pathogen. The mechanisms retained by S. epidermidis that enable colonization of human skin as well as invasive infection, will be described, with a particular focus upon biofilm formation. The host immune responses to these infections are also described, including how S. epidermidis seems to trigger low levels of pro-inflammatory cytokines and high levels of interleukin-10, which may contribute to the sub-acute and persistent nature often associated with these infections. The adaptive immune response to S. epidermidis remains poorly described, and represents an area which may provide significant new discoveries in the coming years.
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Affiliation(s)
- Marina Sabaté Brescó
- Musculoskeletal Infection, AO Research Institute DavosDavos, Switzerland.,Molecular Immunology, Swiss Institute of Allergy and Asthma Research, University of ZurichDavos, Switzerland
| | - Llinos G Harris
- Microbiology and Infectious Diseases, Institute of Life Science, Swansea University Medical SchoolSwansea, United Kingdom
| | - Keith Thompson
- Musculoskeletal Infection, AO Research Institute DavosDavos, Switzerland
| | - Barbara Stanic
- Musculoskeletal Infection, AO Research Institute DavosDavos, Switzerland
| | - Mario Morgenstern
- Department of Orthopedic and Trauma Surgery, University Hospital BaselBasel, Switzerland
| | - Liam O'Mahony
- Molecular Immunology, Swiss Institute of Allergy and Asthma Research, University of ZurichDavos, Switzerland
| | - R Geoff Richards
- Musculoskeletal Infection, AO Research Institute DavosDavos, Switzerland
| | - T Fintan Moriarty
- Musculoskeletal Infection, AO Research Institute DavosDavos, Switzerland
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Nagaya LH, Salles MJC, Takikawa LSC, Fregoneze M, Doneux P, Silva LAD, Sella GDV, Miyazaki AN, Checchia SL. Infections after shoulder arthroplasty are correlated with higher anesthetic risk score: a case-control study in Brazil. Braz J Infect Dis 2017; 21:613-619. [PMID: 28704642 PMCID: PMC9425506 DOI: 10.1016/j.bjid.2017.06.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 05/21/2017] [Accepted: 06/11/2017] [Indexed: 11/05/2022] Open
Abstract
Purposes Shoulder arthroplasty (SA) has been performed by many years for the treatment of several conditions, including osteoarthritis and proximal humeral fractures following trauma. Surgical site infection (SSI) following Shoulder arthroplasty remains a challenge, contributing to increased morbidity and costs. Identification of risk factors may help implementing adequate strategies to prevent infection. We aimed to identify pre- and intra-operative risk factors associated with deep infections after Shoulder arthroplasty. Methods An unmatched case-control study was conducted to describe the prevalence, clinical and microbiological findings, and to evaluate patient and surgical risk factors for prosthetic shoulder infection (PSI), among 158 patients who underwent SA due to any reason, at a tertiary public university institution. Risk factors for PSI was assessed by uni- and multivariate analyses using multiple logistic regression. Results 168 SA from 158 patients were analyzed, with an overall infection rate of 9.5% (16/168 cases). Subjects undergoing SA with American Society of Anesthesiologists (ASA) grade III or higher (odds ratio [OR] = 5.30, 95% confidence interval [CI] = 1.58–17.79, p < 0.013) and presenting local hematoma after surgery (odds ratio [OR] = 7.10, 95% confidence interval [CI] = 1.09–46.09, p = 0.04) had higher risk for PSI on univariate analysis. However, only ASA score grade III or higher remained significant on multivariate analysis (OR = 4.74, 95% CI = 1.33–16.92, p = 0.016). Gram-positive cocci and Gram-negative bacilli were equally isolated in 50% of cases; however, the most commonly detected bacterium was Pseudomonas aeruginosa (18.7%). Conclusion This study provides evidence suggesting that patient-related known factors such as higher ASA score predisposes to shoulder arthroplasty-associated infection. Furthermore, unusual pathogens associated with PSI were identified.
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Affiliation(s)
- Leonardo Hideto Nagaya
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brazil
| | - Mauro José Costa Salles
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Medicina Interna, Secção de Doenças Infecciosas, São Paulo, SP, Brazil.
| | - Lucas Sadawo Chagas Takikawa
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brazil
| | - Marcelo Fregoneze
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brazil
| | - Pedro Doneux
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brazil
| | - Luciana Andrade da Silva
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brazil
| | - Guilherme do Val Sella
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brazil
| | - Alberto Naoki Miyazaki
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brazil
| | - Sergio Luiz Checchia
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brazil
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Jorge LS, Chueire AG, Fucuta PS, Machado MN, Oliveira MGL, Nakazone MA, Salles MJ. Predisposing factors for recurrence of chronic posttraumatic osteomyelitis: a retrospective observational cohort study from a tertiary referral center in Brazil. Patient Saf Surg 2017; 11:17. [PMID: 28588645 PMCID: PMC5457537 DOI: 10.1186/s13037-017-0133-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 05/24/2017] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The incidence of posttraumatic osteomyelitis (PTO) is increasing despite new treatment strategies. Assessment of patients' outcomes following PTO is challenging due to multiple variables. The study goals are to determine the frequency of recurrence following PTO treatment and identify factors predisposing patients to treatment failure. METHODS Between August 01, 2007 to August 30, 2012, a single-center retrospective cohort study was performed among 193 patients diagnosed with PTO following orthopedic surgery for fracture care. Bone and soft tissues were collected for cultures and PTO was defined according to CDC/NHSN criteria. Patient, injury, surgery-associated variables, and microbiological records were reviewed for risk factors associated to recurrence of PTO. Univariate and multivariable analyses using logistic regression were performed, with p <0.05 considered significant. RESULTS Thirty-eight patients (20%) of 192 diagnosed and treated for PTO failed their treatment. Factors associated with recurrence were age between 61 and 80 years [hazard ratio (HR) = 6.086, 95% confidence interval (CI) = 2.459;15.061, p = <0.001], age above 80 years [HR = 9.975 (95% CI = 3.591;27.714), p = <0.001], intraoperative blood transfusion [HR = 2.239 (95% CI = 1.138;4.406), p = 0.020], and positive culture for Pseudomonas aeruginosa [HR = 2.700 (95% CI = 1.370;5.319), p = 0.004]. CONCLUSIONS Risk factors associated with recurrence of PTO are difficult to measure. The present study revealed that elderly patients, intraoperative blood transfusions, and infection due to P. aeruginosa were independently associated with recurrence of PTO. These factors should warn clinicians of a higher failure rate following treatment of PTO. Trial registration: ISRCTN71648577. Registered 18 May 2017. Retrospectively registered.
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Affiliation(s)
- Luciana Souza Jorge
- Hospital de Base, Infection Control Unit, São José do Rio Preto Medical School, São Paulo, Brazil
| | - Alceu G Chueire
- Orthopedics and Traumatology Unit, São José do Rio Preto Medical School, São Paulo, Brazil
| | - Patricia Silva Fucuta
- Orthopedics and Traumatology Unit, São José do Rio Preto Medical School, São Paulo, Brazil
| | - Mauricio N Machado
- Orthopedics and Traumatology Unit, São José do Rio Preto Medical School, São Paulo, Brazil
| | | | - Marcelo A Nakazone
- Orthopedics and Traumatology Unit, São José do Rio Preto Medical School, São Paulo, Brazil
| | - Mauro José Salles
- Division of Infectious Diseases, Department of Internal Medicine, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil.,Hospital da Irmandade da Santa Casa de Misericórdia de São Paulo, Rua Dr Cesáreo Mota Jr 112, CEP: 01221-020 São Paulo, SP Brazil
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48
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Zimmerli W, Sendi P. Orthopaedic biofilm infections. APMIS 2017; 125:353-364. [PMID: 28407423 DOI: 10.1111/apm.12687] [Citation(s) in RCA: 192] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 01/10/2017] [Indexed: 02/01/2023]
Abstract
Many infections of the musculoskeletal system are biofilm infections that develop on non-living surfaces. Microorganisms adhere either on dead bone (sequesters) or implants. As a rule for a curative concept, chronic osteomyelitis or implant-associated bone infection must be treated with a combination of surgery and antimicrobial therapy. If an implant is kept in place, or a new device is implanted before complete healing of infection, a biofilm-active antibiotic should be used. Rifamycins are active against biofilms of staphylococci, and fluoroquinolones against those of Gram-negative bacilli. In this review, the management of chronic osteomyelitis, periprosthetic joint infection and implant-associated osteomyelitis of long bones is presented.
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Affiliation(s)
- Werner Zimmerli
- Kantonsspital Baselland, Basel University Medical Clinic and Interdisciplinary Unit for Orthopaedic Infections, Liestal, Switzerland
| | - Parham Sendi
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
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Fang C, Wong TM, Lau TW, To KK, Wong SS, Leung F. Infection after fracture osteosynthesis - Part I. J Orthop Surg (Hong Kong) 2017; 25:2309499017692712. [PMID: 28215118 DOI: 10.1177/2309499017692712] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Bone and surgical site infections after osteosynthesis are notoriously difficult to manage and pose a tremendous burden in fracture management. In this article, we use the term osteosynthesis-associated infection (OAI) to refer to this clinical entity. While relatively few surgically treated fractures become infected, it is challenging to perform a rapid diagnosis. Optimal management strategies are complex and highly customized to each scenario and take into consideration the status of fracture union, the presence of hardware and the degree of mechanical stability. At present, a high level of relevant evidence is unavailable; most findings presented in the literature are based on laboratory work and non-randomized clinical studies. We present this overview of OAI in two parts: an examination of recent literature concerning OAI pathogenesis, diagnosis and classification and a review of treatment options.
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Affiliation(s)
- Christian Fang
- 1 Department of Orthopaedics and Traumatology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong, China
| | - Tak-Man Wong
- 1 Department of Orthopaedics and Traumatology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong, China.,3 Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Tak-Wing Lau
- 1 Department of Orthopaedics and Traumatology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong, China
| | - Kelvin Kw To
- 2 Department of Microbiology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong, China
| | - Samson Sy Wong
- 2 Department of Microbiology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong, China
| | - Frankie Leung
- 1 Department of Orthopaedics and Traumatology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong, China.,3 Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, University of Hong Kong-Shenzhen Hospital, Shenzhen, China
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Conen A, Fux CA, Vajkoczy P, Trampuz A. Management of infections associated with neurosurgical implanted devices. Expert Rev Anti Infect Ther 2016; 15:241-255. [PMID: 27910709 DOI: 10.1080/14787210.2017.1267563] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Neurosurgical devices are increasingly used. With it, neurosurgical device-related infections gain relevance. As biofilms are involved in implant-associated infections the diagnosis and treatment is challenging and requires specific anti-biofilm concepts and management algorithms. Areas covered: The literature concerning the management of neurosurgical device-associated infections is scarce and heterogeneous treatment concepts are discussed, but no standardized diagnostic and treatment procedures exist. Therefore, we emphasize extrapolating management strategies predominantly from orthopedic device-associated infections, where the concept is better established and clinically validated. This review covers infections associated with craniotomy fixation devices, cranioplasties, external ventricular and lumbar drainages, internal shunts and neurostimulators. Expert commentary: Sonication of the removed implants significantly improves microbiological diagnosis. A combined surgical and antimicrobial management is crucial for successful treatment: appropriate surgical intervention is combined with prolonged anti-biofilm therapy of usually 12 weeks. In selected patients, new treatment algorithms enable cure of neurosurgical device-associated infections without implant removal or with a one-stage implant exchange, considerably improving the quality of patient lives.
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Affiliation(s)
- Anna Conen
- a Clinic of Infectious Diseases and Hospital Hygiene , Department of Internal Medicine, Kantonsspital Aarau , Aarau , Switzerland
| | - Christoph A Fux
- a Clinic of Infectious Diseases and Hospital Hygiene , Department of Internal Medicine, Kantonsspital Aarau , Aarau , Switzerland
| | - Peter Vajkoczy
- b Department of Neurosurgery , Charité - Universitätsmedizin Berlin , Berlin , Germany
| | - Andrej Trampuz
- c Center for Musculoskeletal Surgery , Charité - Universitätsmedizin Berlin , Berlin , Germany
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