Successful treatment of a prosthetic joint infection due to Mycobacterium abscessus

Management of M. abscessus subsp. abscessus early-onset prosthetic joint infection: Case report and literature review

Nontuberculous mycobacteria are a rare but still emerging cause of difficult-to-treat prosthetic joint infection. To our knowledge only 17 cases of M. abscessus complex prosthetic joint infection are reported in literature, of which only 1 is by M. abscessus subps. abscessus. No guidelines are available for this clinical scenario. We describe a 68-years-old female patient with an early-onset M. abscessus subsp. abscessus prosthetic joint infection, successfully treated with a tailored medical-surgical strategy, and present an overview of cases currently available in the literature to assist physicians in the management of these uncommon infections.

Non-Tuberculosis Mycobacterium Periprosthetic Joint Infections Following Total Hip and Knee Arthroplasty: Case Series and Review of the Literature

OBJECTIVE

Periprosthetic joint infection (PJI) caused by non-tubercular mycobacteria (NTM) is uncommon but catastrophic. However, conclusive clinical data on PJI caused by NTM are lacking. In this case series and systematic review, the clinical manifestations, diagnosis, and management of NTM PJI are summarized and analyzed.

METHODS

From 2012 to 2020, we retrospectively analyzed consecutive PJI cases caused by NTM in our institution. A literature review was also conducted from January 2000 to December 2021, utilizing the PubMed, MEDLINE, Cochrane Library, and EMBASE databases to identify all reported NTM-induced PJI cases. The clinical characteristics, demographics, pathogen identification, treatment protocols, and prognosis of NTM PJI were summarized and analyzed.

RESULTS

In this retrospective analysis, seven patients infected with NTM following total joint arthroplasty at our institution were included, including six cases of PJI caused by NTM and one case of septic arthritis (SA) caused by NTM. There were six men and one woman, and their average age was 62.3 years. The average interval between TJA and PJI onset was 4 months. The preoperative serological markers, including the mean ESR (51 mm/h), CRP (4.0 mg/dL), fibrinogen (5.7 g/L), and D-dimer (1.1 g/L), were increased. Six patients underwent staged revision surgery, and one patient with SA received antibiotic-loaded bone cement beads to treat the infection. After an average of 33 months of observation following surgical intervention, none of the patients showed any symptoms of infection recurrence. From 2000 to 2021, 68 patients with NTM PJI were found in 39 studies in the published literature. Reinfections occurred within 1 year after arthroplasty in more than half (53.2%) of the patients. M. fortuitum and M. abscesses were the most prevalent rapidly growing mycobacteria (RGM) in all PJI patients, whereas Mycobacterium avium intracellulare (MAC) was the most prevalent slowly growing mycobacterium (SGM). The corresponding antibiotics were amikacin and ethambutol. The rate of culture-negative without specific clinical symptoms was as high as 36.4% (12/33), while 45% (18/40) utilized additional diagnostic techniques such as NGS. A final clinical follow-up record was available for 59 patients (86.7%; mean follow-up period, 29 months), and 10.1% of patients failed to respond to treatment.

CONCLUSION

Orthopaedic surgeons should consider NTM in patients with negative routine cultures who are at risk for Mycobacterium infection. Treatment options rely on the accurate result of microbiologic identification and drug sensitivity testing, and to achieve this, it may be necessary to send multiple culture specimens, extend the culture time, and change the culture medium. Every effort should be made to identify NTM and its various subtypes through modern diagnostic tools if necessary.

Mycobacterium abscessus Periprosthetic Hip Infection Complicated by Superimposed Polymicrobial Infection: A Case Report

CASE

A 79-year-old man developed Mycobacterium abscessus prosthetic joint infection (PJI) after hip hemiarthroplasty that was complicated by polymicrobial infection. He was ultimately treated with resection arthroplasty and chronic suppressive therapy. He has had no evidence of recurrent infection after 2 years of follow-up.

CONCLUSION

As far as we know, this is the first reported case of M. abscessus hip PJI complicated by superimposed polymicrobial infection. This case demonstrates the challenge of treating M. abscessus infection, the need for a multidisciplinary approach with aggressive surgical intervention, and prolonged combination antimicrobial therapy for a successful outcome.

Mycobacterium fortuitum Prosthetic Joint Infection After Total Hip Arthroplasty: A Case Report

CASE

A 57-year-old man presented with a Mycobacterium fortuitum prosthetic joint infection (PJI) after right total hip arthroplasty refractory to the initial revision surgery and cement spacer placement. The patient was subsequently treated with 2-stage total joint arthroplasty revision surgery using an antibiotic-laden spacer customized to include meropenem and delayed reimplantation to allow for prolonged, systemic antimicrobial treatment with multiple antimicrobials, including levofloxacin and linezolid.

CONCLUSIONS

There is little evidence to guide practitioners in the diagnosis and treatment of PJI caused by rare, rapidly growing mycobacteria (RGM) such as M. fortuitum. This case demonstrates a successful strategy for the treatment of RGM PJI.

Mycobacterium bolletii Osteomyelitis of the Metaphyseal Distal Radius Treated With Amikacin Antibiotic Beads

Mycobacterium bollettii, a subset of the group M. abscessus, is a slow-growing, nontuberculous mycobacterium that was first characterized in the early 2000s. We report a case of M. bollettii infection in an otherwise healthy 49-year-old man who sustained an open fracture of the right distal radius. After his initial surgery, the patient presented 1 month later with wound drainage requiring hardware removal and was treated with intravenous antibiotics. However, there was a persistent infection. We treated his osteomyelitis with debridement and placement of amikacin antibiotic beads. We selected this particularly uncommon antibiotic cement specifically to address the nontuberculous mycobacterium. The purpose of this report is to alert treating providers to the possibility of nontuberculous mycobacterium infections when an inflammatory process persists and to provide guidelines for the use of amikacin solution to produce antibiotic beads.

Mycobacterium abscessus urinary tract infection: case report

Urinary tract infection is a serious public health issue that predominantly affects women. In men, it is more often associated with prostatic hyperplasia and bladder catheterization. Urogenital tuberculosis presents with nonspecific with nonspecific symptoms and the diagnosis can be made in the presence of sterile leukocyturia and recurrent infection with acid urine. Non-tuberculous mycobacteria or other non-tuberculosis mycobacteria are opportunistic pathogens that inhabit the soil, water or environment surfaces, and usually cause diseases in immunocompromised individuals. Mycobacterium abscessus is an agent that causes lung, skin and soft tissue hospital infections. Urinary tract infections by this pathogen are rare.

Mycobacterium abscessus Periprosthetic joint infection following bilateral Total Knee arthroplasty

Periprosthetic joint infection (PJI) can be protracted, incapacitating, needing multiple interventions and could even lead to mortality. Early post-operative PJI has been ascribed to peri-operative introduction of highly virulent bacteria, while delayed post-operative to low-virulence bacteria. Non-tuberculous mycobacteria (NTM) do not figure in the usual list of etiological agents. We report a case of difficult diagnosis of bilateral PJI caused by Mycobacterium abscessus, following bilateral total knee arthroplasty in an elderly male, but treated successfully despite prolonged infection. M. abscessus complex comprises a group of rapidly growing, multidrug-resistant NTM, capable of forming biofilms on prostheses, responsible for wide spectrum of hospital acquired infections. M. abscessus as a cause of PJI is not reported widely. There are a few cases described in literature worldwide. There are no policy guidelines available for treating such cases. High clinical suspicion, with a concerted effort to grow and identify the causal pathogen is important. Standard anti-tubercular therapy is not recommended for treatment due to inherent resistance. Complete excision of infected tissues and removal of prosthesis along with prolonged combination antimicrobial regimen is the treatment of choice.

Prosthetic knee joint infection due to Mycobacterium abscessus

Infected total knee arthroplasty (TKA) due to Mycobacterium abscessus is very rare with only three such cases described in literature. Only one case was managed successfully, however, with a prolonged course of anti tubercular therapy. In this case report, we present an elderly lady with infected TKA after 2 years of the primary procedure. Although initially it grew different bacteriae, M. abscessus was isolated during the second debridement. She was successfully treated with total of 5 months of second line anti tubercular drugs with revision prosthesis performed during chemotherapy. Two years followup revealed satisfactory outcome with no relapse.

Gastric lap-band infection due to Mycobacterium abscessus presenting as new-onset ascites in a cirrhotic patient

Nontuberculous mycobacteria are ubiquitous environmental organisms that are infrequently implicated as pathogens. Peritoneal infection with nontuberculous mycobacteria is rare and published reports are most commonly associated with peritoneal dialysis. This study describes a case of a 41-year-old woman with cirrhosis who had Mycobacterium abscessus peritonitis and an abdominal abscess resulting from infection of a remotely placed gastric band (Lap-Band; Apollo Endosurgery, Inc).

Drug treatments for prosthetic joint infections in the era of multidrug resistance

INTRODUCTION

Despite many advances, the management of prosthetic joint infection is still a complex issue. Moreover, in recent years the problem of antimicrobial resistance has emerged as an important challenge.

AREAS COVERED

We analysed recent advances in different aspects of prosthetic joint infections. The importance of biofilms needs to be considered for antibiotic selection because, when embedded in these structures, bacteria acquire resistant behaviour. Moreover, the presence of resistance mechanisms in some species of organisms increases the difficulty of management. In this sense, the growing importance of methicillin-resistant staphylococci, multidrug-resistant Enterobacteriaceae or Pseudomonas aeruginosa is of increasing concern. Together with these organisms, others with constitutive resistance against most antibiotics (like Enterococcus sp., mycobacteria or fungi) represent a similar problem for selection of therapy. Research into new materials that can be used as drug carriers opens a new field for management of these infections and will likely come to the front line in the coming years.

EXPERT OPINION

Individualised therapies should carefully consider the aetiology, pathogenesis and antimicrobial susceptibility. Satisfactory clinical outcome could be further fostered by enhancing the multidisciplinary approach, with better collaboration in the antibiotic selection and the surgical management.

Prosthetic joint infections secondary to rapidly growing mycobacteria: Two case reports and a review of the literature

Rapidly growing mycobacteria (RGM) are a rare but treatable cause of prosthetic joint infections. This study reports on two patients comprising three prosthetic joint infections caused by RGM successfully treated at the institution. With removal of the infected prosthetic joint and judicious use of prolonged courses of antibiotics, patients with prosthetic joint infections secondary to RGM can both be cured and retain function of the affected joint. In addition, this study identified 40 additional cases reported during an extensive review of the literature and provide a summary of these cases. These infections can present within days of arthroplasty or can develop only decades after the index surgery. The clinical presentations often mimic those of more routine bacterial prosthetic joint infections.

Mycobacterium abscessus peritonitis associated with laparoscopic gastric banding

Background

Mycobacterium abscessus is a rapidly growing Mycobacterium that is a common water contaminant in the environment. We report a case of M. abscessus infection with band erosion following laparoscopic gastric banding.

Case presentation

A 34-year-old woman developed insidiously progressing abdominal distension over a period of 1 year associated with abdominal pain, fatigue, night sweating and anorexia 4 years after laparoscopic gastric banding for obesity. Investigation revealed significant ascites with caseating granuloma in peritoneal biopsies from which M. abscessus was isolated. Band erosion with infection and multiple abdominal adhesions were confirmed during laparoscopic removal of the gastric band. To the best of our knowledge, this is the first reported case of M. abscessus infection after laparoscopic gastric banding surgery. We discuss the possible sources of infection, its indolent presentation, and therapeutic challenges.

Conclusion

It is important to consider environmentally acquired infection in patients with signs and symptoms of infection in the presence of surgical prosthesis.