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Tsikopoulos K, Meroni G. Periprosthetic Joint Infection Diagnosis: A Narrative Review. Antibiotics (Basel) 2023; 12:1485. [PMID: 37887186 PMCID: PMC10604393 DOI: 10.3390/antibiotics12101485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 09/20/2023] [Accepted: 09/25/2023] [Indexed: 10/28/2023] Open
Abstract
Replacement of native joints aims to restore patients' quality of life by relieving pain and improving joint function. While periprosthetic joint infection (PJI) affects a small percentage of patients, with an estimated incidence of 1-9% following primary total joint replacement, this postoperative complication necessitates a lengthy hospitalisation, extended antibiotic treatment and further surgery. It is highlighted that establishing the correct diagnosis of periprosthetic infections is critical in order for clinicians to avoid unnecessary treatments in patients with aseptic failure. Of note, the PJI diagnosis could not purely rely upon clinical manifestations given the fact that heterogeneity in host factors (e.g., age and comorbidities), variability in infection period, difference in anatomical location of the involved joint and discrepancies in pathogenicity/virulence of the causative organisms may confound the clinical picture. Furthermore, intra-operative contamination is considered to be the main culprit that can result in early or delayed infection, with the hematogenous spread being the most prevalent mode. To elaborate, early and hematogenous infections often start suddenly, whereas chronic late infections are induced by less virulent bacteria and tend to manifest in a more quiescent manner. Last but not least, viruses and fungal microorganisms exert a role in PJI pathogenesis.
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Affiliation(s)
- Konstantinos Tsikopoulos
- 1st Department of Pharmacology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
| | - Gabriele Meroni
- One Health Unit, Department of Biomedical, Surgical and Dental Sciences, School of Medicine, University of Milan, 20133 Milan, Italy;
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Kang A, Lee H, Roh Y, Kim D, Jeong SM, Jeong J. Case report: Three-dimensionally printed patient-specific acetabular cage for revision surgery of aseptic loosening in a dog with micro total hip replacement. Front Vet Sci 2022; 9:915639. [PMID: 36337186 PMCID: PMC9626995 DOI: 10.3389/fvets.2022.915639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 10/06/2022] [Indexed: 11/13/2022] Open
Abstract
A 2-year-old castrated male Pomeranian dog was presented for regular follow-up after micro total hip replacement (mTHR) 16 months prior to presentation. Clinically, the dog did not show any noticeable lameness of the left hindlimb, except for external rotation during walking. However, radiographic findings, namely rotation and medialization of the acetabular cup with a periprosthetic lucent line and bone formation medial to the acetabulum, were interpreted as aseptic loosening of the acetabular component. Because the dog was incompatible with the conventional THR revision method owing to severe bone defects in the acetabulum, a patient-specific titanium acetabular cage prosthesis with biflanges and four cranial and one caudal screw hole was designed for revision surgery. A custom-made acetabular cage was prepared, and it had a 12-mm polyethylene cup fixed with polymethylmethacrylate bone cement and positioned in the acetabulum. After the custom-made acetabular cage was anchored to the pelvic bone with the five cortical screws, reduction of the prostheses was achieved smoothly. The dog showed almost normal limb function without external rotation of the left hindlimb 2 weeks postoperatively. Bone remodeling and stable implant position were noted on radiographic images 3 years after revision surgery, with no evidence of loosening. Based on the clinical outcomes, the use of a custom-made acetabular prosthesis can be an effective treatment option for revision arthroplasty in acetabula with severe bone loss and structural changes in small-breed dogs.
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Affiliation(s)
- AhRan Kang
- College of Veterinary Medicine, Chungnam National University, Daejeon, South Korea
| | - Haebeom Lee
- College of Veterinary Medicine, Chungnam National University, Daejeon, South Korea
| | - Yoonho Roh
- Division of Small Animal Surgery, Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Daehyun Kim
- College of Veterinary Medicine, Chungnam National University, Daejeon, South Korea
| | - Seong Mok Jeong
- College of Veterinary Medicine, Chungnam National University, Daejeon, South Korea
| | - Jaemin Jeong
- College of Veterinary Medicine, Chungnam National University, Daejeon, South Korea
- *Correspondence: Jaemin Jeong
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Cichos KH, Detweiler M, Parvizi J, McGwin G, Heatherly AR, Ghanem ES. The fate of positive intraoperative cultures following conversion total hip arthroplasty. Hip Int 2022; 32:17-24. [PMID: 32573261 DOI: 10.1177/1120700020936628] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The objectives of this study are to report the rates of positive intraoperative cultures obtained during conversion total hip arthroplasty (THA) according to index surgery, and to describe the natural history of treatment for a consecutive series of patients with unexpected positive intraoperative cultures during conversion THA. METHODS We reviewed all patients at 2 institutions undergoing conversion THA from prior open reduction and internal fixation (ORIF) of acetabular and hip fractures or hemiarthroplasty for displaced femoral neck fractures from 2011 to 2018. Intraoperative cultures were taken in 105 patients. Positive intraoperative cultures during conversion were recorded and managed with an infectious diseases consult. The outcomes including PJI at 90 days and 1 year follow-up were documented. RESULTS Overall, 19 of 105 patients (18%) undergoing conversion THA had positive intraoperative cultures, with the highest rates in the hemiarthroplasty 7/16 (44%) and acetabular ORIF 9/48 (19%) groups. All 19 patients were initially treated conservatively: 8 received IV antibiotics, 10 received no additional therapy, and 1 received oral antibiotics. 4/9 acetabular fracture conversions developed PJI at 1 year, with 3 requiring multiple irrigation and debridement/polyethylene exchanges to control the infection while the 4th patient required 2-stage exchange. There were no 1-year PJI from any of the other index procedures after conversion. All 7 hemiarthroplasty patients with positive cultures were treated to resolution with 4-8 weeks IV antibiotics alone. CONCLUSIONS Patients undergoing conversion THA from prior hip or acetabular fracture have a high rate of positive intraoperative cultures. As such, all patients undergoing conversion THA from prior hip or acetabular fracture fixation should undergo thorough diagnostic workup prior to surgery, and have intraoperative cultures obtained during surgery if infection remains suspicious. Further work should be performed to develop MSIS criteria for preoperative management of patients undergoing conversion THA.
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Affiliation(s)
- Kyle H Cichos
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Maxwell Detweiler
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Javad Parvizi
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Gerald McGwin
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Elie S Ghanem
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Stephan A, Thürmer A, Glauche I, Nowotny J, Zwingenberger S, Stiehler M. Does preoperative antibiotic prophylaxis affect sonication-based diagnosis in implant-associated infection? J Orthop Res 2021; 39:2646-2652. [PMID: 33620104 DOI: 10.1002/jor.25015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 02/15/2021] [Accepted: 02/21/2021] [Indexed: 02/04/2023]
Abstract
As culture-negative implant-associated infection denote a diagnostic challenge, sonicate fluid cultures of the explanted endoprosthesis and osteosynthesis components are frequently used. However, the effect of antibiotic treatment on pathogen detection by sonication fluid cultures in implant-associated infection has not been investigated. Thus, the aim of this study was to evaluate the influence of preoperative antibiotic prophylaxis (PAP) and antibiotic therapy (AT) on sonicate fluid cultures in patients with implant-associated infection. In this retrospective study three groups were compared: (i) standard PAP, (ii) AT for at least one day, and (iii) no antibiotics before surgery. For the inclusion criteria, an established diagnostic protocol for implant-associated infection was used. Sonicate fluid cultures were validated by corresponding microbiological and histopathological samples. In 90 patients with single and multiple infections, 114 pathogens were detected. The detection rate by sonicate fluid cultures in patients receiving PAP (n = 27, 29 pathogens), AT before surgery (n = 33, 48 pathogens) and no antibiotics before surgery (n = 30, 37 pathogens) were 86.2%, 81.3%, and 86.5% (p = .778), respectively. Eleven of 114 infectious agents were detected exclusively by sonicate fluid cultures, while conventional tissue culture failed in these cases. PAP and AT do not affect intraoperative cultures in implant-associated infection. It is therefore not recommended to omit antibiotic prophylaxis in patients with implant-associated infection. Algorithms including both sonicate fluid cultures and tissue samples should be used for appropriate microbiological diagnosis of implant-associated infections.
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Affiliation(s)
- Anna Stephan
- University Centre for Orthopaedics, Traumatology and Plastic Surgery, Dresden, Germany
| | - Alexander Thürmer
- University Centre for Orthopaedics, Traumatology and Plastic Surgery, Dresden, Germany
| | | | - Jörg Nowotny
- University Centre for Orthopaedics, Traumatology and Plastic Surgery, Dresden, Germany
| | - Stefan Zwingenberger
- University Centre for Orthopaedics, Traumatology and Plastic Surgery, Dresden, Germany
| | - Maik Stiehler
- University Centre for Orthopaedics, Traumatology and Plastic Surgery, Dresden, Germany
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Barker CJ, Marriot A, Khan M, Oswald T, Tingle SJ, Partington PF, Carluke I, Reed MR. Hip aspiration culture: analysing data from a single operator series investigating periprosthetic joint infection. J Bone Jt Infect 2021; 6:165-170. [PMID: 34084706 PMCID: PMC8137858 DOI: 10.5194/jbji-6-165-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 04/09/2021] [Indexed: 01/29/2023] Open
Abstract
Introduction:
We undertook this study to know the sensitivity, specificity and post-test
probabilities of hip aspiration when diagnosing periprosthetic hip infections. We also examined “dry tap” (injection with saline and
aspiration) results and aspiration volumes.
Methods:
This is a retrospective cohort study of patients aspirated for suspected
periprosthetic joint infection between July 2012 and October 2016. All aspirations were carried out by one trained surgical care practitioner
(SCP). All aspirations followed an aseptic technique and fluoroscopic guidance. Aspiration was compared to tissue biopsy taken at revision.
Aspiration volumes were analysed for comparison.
Results:
Between January 2012 and September 2016, 461 hip aspirations were performed
by our SCP. Of these 125 progressed to revision. We calculated sensitivity
59 % (confidence interval (CI) 35 %–82 %) and specificity 94 % (CI
89 %–98 %). Pre-test probability for our cohort was 0.14. Positive post-test
probability was 0.59 and negative post-test probability 0.06. Aspiration
volume for infected (n=17) and non-infected (n=108) joints was compared
and showed no significant difference. Dry taps were experienced five times; in each instance the dry tap agreed with the biopsy result.
Conclusions:
Our data show that hip aspiration culture is a highly specific investigation
for diagnosing infection but that it is not sensitive. Aspiration volume
showed no significant difference between infected and non-infected groups.
Each time a joint was infiltrated with saline to achieve a result, the result matched tissue sampling.
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Affiliation(s)
| | - Alan Marriot
- Northumbria Healthcare NHS Foundation Trust, Cramlington, NE23 6NZ, UK
| | - Munir Khan
- Northumbria Healthcare NHS Foundation trust, Cramlington, NE23 6NZ, UK
| | - Tamsin Oswald
- Northumbria Healthcare NHS Foundation Trust, Cramlington, NE23 6NZ, UK
| | - Samuel J Tingle
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK
| | - Paul F Partington
- Northumbria Healthcare NHS Foundation Trust, Cramlington, NE23 6NZ, UK
| | - Ian Carluke
- Northumbria Healthcare NHS Foundation Trust, Cramlington, NE23 6NZ, UK
| | - Mike R Reed
- Northumbria Healthcare NHS Foundation Trust, Cramlington, NE23 6NZ, UK
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In Vitro and In Vivo Evaluation of 99mTc-Polymyxin B for Specific Targeting of Gram-Bacteria. Biomolecules 2021; 11:biom11020232. [PMID: 33562877 PMCID: PMC7915610 DOI: 10.3390/biom11020232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 01/31/2021] [Accepted: 02/01/2021] [Indexed: 02/06/2023] Open
Abstract
Background: Infectious diseases are one of the main causes of morbidity and mortality worldwide. Nuclear molecular imaging would be of great help to non-invasively discriminate between septic and sterile inflammation through available radiopharmaceuticals, as none is currently available for clinical practice. Here, we describe the radiolabeling procedure and in vitro and in vivo studies of 99mTc-polymyxin B sulfate (PMB) as a new single photon emission imaging agent for the characterization of infections due to Gram-negative bacteria. Results: Labeling efficiency was 97 ± 2% with an average molar activity of 29.5 ± 0.6 MBq/nmol. The product was highly stable in saline and serum up to 6 h. In vitro binding assay showed significant displaceable binding to Gram-negative bacteria but not to Gram-positive controls. In mice, 99mTc-HYNIC-PMB was mainly taken up by liver and kidneys. Targeting studies confirmed the specificity of 99mTc-HYNIC-PMB obtained in vitro, showing significantly higher T/B ratios for Gram-negative bacteria than Gram-positive controls. Conclusions: In vitro and in vivo results suggest that 99mTc-HYNIC-PMB has a potential for in vivo identification of Gram-negative bacteria in patients with infections of unknown etiology. However, further investigations are needed to deeply understand the mechanism of action and behavior of 99mTc-HYNIC-PMB in other animal models and in humans.
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Babu S, Vaishya R, Butta H, Sardana R, Mehndiratta L, Gulati Y, Kharbanda Y, Tandon H. A retrospective analysis of the prosthetic joint infections of the hip and knee at a tertiary care center of India. APOLLO MEDICINE 2021. [DOI: 10.4103/am.am_9_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Shin CH, Lim C, Kim TS, Choi EH, Cho TJ, Choi IH, Yoo WJ. Effective and Rapid Microbial Identification in Pediatric Osteoarticular Infections Using Blood Culture Bottles. J Bone Joint Surg Am 2020; 102:1792-1798. [PMID: 33086346 DOI: 10.2106/jbjs.20.00219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The detection and identification of pathogenic microorganisms are essential for the treatment of osteoarticular infection. However, obtaining a sufficient amount of specimen from pediatric patients is often difficult. Herein, we aimed to demonstrate the effectiveness of the blood culture bottle (BCB) system in pediatric osteoarticular infections. We hypothesized that our BCB culture method is superior to the conventional swab and tissue culture methods in terms of required specimen size, incubation time, and microbial identification rate. METHODS We analyzed the prospectively collected data of pediatric patients who underwent surgical treatment for osteoarticular infections between August 2016 and October 2019. Four needles were dipped in the infected fluid or tissue during the surgical procedure as soon as the infected area was exposed and were used to inoculate 2 aerobic pediatric BCBs and 2 anaerobic general BCBs. We also collected 2 conventional swab samples and 2 tissue samples from the identical area. The microbial identification rate and the time required for identification were compared between BCB, swab, and tissue cultures. RESULTS Forty patients constituted the study group; 13 patients had osteomyelitis, 17 patients had septic arthritis, and 10 patients had both. Of these 40 patients, the microbial identification rate was higher with BCB cultures (27 [68%]) than with swab cultures (18 [45%]; p = 0.004) or tissue cultures (15 [38%]; p < 0.001). Nine samples (9 patients [23%]) were only positive in the BCB culture. Positive microbial growth was not detected with conventional culture methods when microorganisms did not grow on the BCB culture. Compared with swab culture (4.3 ± 1.1 days; p < 0.001) or tissue culture (4.4 ± 1.1 days; p < 0.001), the BCB culture reduced the time required for microbial identification (3.5 ± 0.9 days). CONCLUSIONS In pediatric osteoarticular infections, the BCB culture system improved the microbial identification rate, reduced the time to identification, and permitted a smaller-volume specimen, compared with traditional culture systems. LEVEL OF EVIDENCE Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Chang Ho Shin
- Divisions of Pediatric Orthopaedics (C.H.S., T.-J.C., I.H.C., and W.J.Y.), and Pediatrics (E.H.C.), Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Chaemoon Lim
- Department of Orthopaedic Surgery, Jeju National University Hospital, Jeju, Republic of Korea
| | - Taek Soo Kim
- Department of Laboratory Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eun Hwa Choi
- Divisions of Pediatric Orthopaedics (C.H.S., T.-J.C., I.H.C., and W.J.Y.), and Pediatrics (E.H.C.), Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Tae-Joon Cho
- Divisions of Pediatric Orthopaedics (C.H.S., T.-J.C., I.H.C., and W.J.Y.), and Pediatrics (E.H.C.), Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - In Ho Choi
- Divisions of Pediatric Orthopaedics (C.H.S., T.-J.C., I.H.C., and W.J.Y.), and Pediatrics (E.H.C.), Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Won Joon Yoo
- Divisions of Pediatric Orthopaedics (C.H.S., T.-J.C., I.H.C., and W.J.Y.), and Pediatrics (E.H.C.), Seoul National University Children's Hospital, Seoul, Republic of Korea
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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:jcm8070933. [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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Carli AV, Abdelbary H, Ahmadzai N, Cheng W, Shea B, Hutton B, Sniderman J, Philip Sanders BS, Esmaeilisaraji L, Skidmore B, Gauthier-Kwan OY, Bunting AC, Gauthier P, Crnic A, Logishetty K, Moher D, Fergusson D, Beaulé PE. Diagnostic Accuracy of Serum, Synovial, and Tissue Testing for Chronic Periprosthetic Joint Infection After Hip and Knee Replacements: A Systematic Review. J Bone Joint Surg Am 2019; 101:635-649. [PMID: 30946198 DOI: 10.2106/jbjs.18.00632] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Chronic periprosthetic joint infection (PJI) is a devastating complication that can occur following total joint replacement. Patients with chronic PJI report a substantially lower quality of life and face a higher risk of short-term mortality. Establishing a diagnosis of chronic PJI is challenging because of conflicting guidelines, numerous tests, and limited evidence. Delays in diagnosing PJI are associated with poorer outcomes and morbid revision surgery. The purpose of this systematic review was to compare the diagnostic accuracy of serum, synovial, and tissue-based tests for chronic PJI. METHODS This review adheres to the Cochrane Collaboration's diagnostic test accuracy methods for evidence searching and syntheses. A detailed search of MEDLINE, Embase, the Cochrane Library, and the grey literature was performed to identify studies involving the diagnosis of chronic PJI in patients with hip or knee replacement. Eligible studies were assessed for quality and bias using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Meta-analyses were performed on tests with sufficient data points. Summary estimates and hierarchical summary receiver operating characteristic (HSROC) curves were obtained using a bivariate model. RESULTS A total of 12,616 citations were identified, and 203 studies met the inclusion criteria. Of these 203 studies, 170 had a high risk of bias. Eighty-three unique PJI diagnostic tests were identified, and 17 underwent meta-analyses. Laboratory-based synovial alpha-defensin tests and leukocyte esterase reagent (LER) strips (2+) had the best performance, followed by white blood-cell (WBC) count, measurement of synovial C-reactive protein (CRP) level, measurement of the polymorphonuclear neutrophil percentage (PMN%), and the alpha-defensin lateral flow test kit (Youden index ranging from 0.78 to 0.94). Tissue-based tests and 3 serum tests (measurement of interleukin-6 [IL-6] level, CRP level, and erythrocyte sedimentation rate [ESR]) had a Youden index between 0.61 to 0.75 but exhibited poorer performance compared with the synovial tests mentioned above. CONCLUSIONS The quality of the literature pertaining to chronic PJI diagnostic tests is heterogeneous, and the studies are at a high risk for bias. We believe that greater transparency and more complete reporting in studies of diagnostic test results should be mandated by peer-reviewed journals. The available literature suggests that several synovial fluid-based tests perform well for diagnosing chronic PJI and their use is recommended in the work-up of any suspected case of chronic PJI. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alberto V Carli
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Hesham Abdelbary
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Nadera Ahmadzai
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Wei Cheng
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Beverley Shea
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jhase Sniderman
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Leila Esmaeilisaraji
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Becky Skidmore
- Independent Information Specialist, Ottawa, Ontario, Canada
| | | | | | - Paul Gauthier
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Agnes Crnic
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - David Moher
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dean Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Paul E Beaulé
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
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Usefulness of Culturing the Periprosthetic Membrane or Neosynovium for the Diagnosis of Infection During Hip and Knee Revision Arthroplasty. J Am Acad Orthop Surg 2018; 26:e442-e447. [PMID: 30102651 DOI: 10.5435/jaaos-d-16-00583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Identification of microorganisms is critical for correct management of an infected arthroplasty. Our hypothesis is that the culture yield depends on the location around the prosthesis from which samples are obtained. METHODS This prospective study included 298 revisions of the hip (123) and knee (175). We compared the yield of the intraoperative samples obtained, which included synovial fluid (two), neosynovium (two), and periprosthetic membrane (two). RESULTS Cultures were positive in 28 cases, in which 15 had the same diagnosis considering either the neosynovium or the membrane, and there were 3 cases in which the infection could have been diagnosed only by considering the combination of both. In all, there were 8 cases in which the infection might have been misdiagnosed unless considering a combination of both solid tissue samples (P = 0.004). CONCLUSIONS The yields of the periprosthetic membrane and neosynovium do not differ significantly, and we recommend considering a combination of both. LEVEL OF EVIDENCE Diagnostic Level II.
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12
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Sebastian S, Malhotra R, Dhawan B. Prosthetic Joint Infection: A Major Threat to Successful Total Joint Arthroplasty. Indian J Med Microbiol 2018; 36:475-487. [DOI: 10.4103/ijmm.ijmm_19_11] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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13
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Wouthuyzen-Bakker M, Benito N, Soriano A. The Effect of Preoperative Antimicrobial Prophylaxis on Intraoperative Culture Results in Patients with a Suspected or Confirmed Prosthetic Joint Infection: a Systematic Review. J Clin Microbiol 2017; 55:2765-2774. [PMID: 28659322 PMCID: PMC5648712 DOI: 10.1128/jcm.00640-17] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 06/23/2017] [Indexed: 02/08/2023] Open
Abstract
Obtaining reliable cultures during revision arthroplasty is important to adequately diagnose and treat a prosthetic joint infection (PJI). The influence of antimicrobial prophylaxis on culture results remains unclear. Since withholding prophylaxis increases the risk for surgical site infections, clarification on this topic is critical. A systematic review was performed with the following research question: in patients who undergo revision surgery of a prosthetic joint, does preoperative antimicrobial prophylaxis affect the culture yield of intraoperative samples in comparison with nonpreoperative antimicrobial prophylaxis? Seven articles were included in the final analysis. In most studies, standard diagnostic culture techniques were used. In patients with a PJI, pooled analysis showed a culture yield of 88% (145/165) in the prophylaxis group versus 95% (344/362) in the nonprophylaxis group (P = 0.004). Subanalysis of patients with chronic PJIs showed positive cultures in 88% (78/89) versus 91% (52/57), respectively (P = 0.59). In patients with a suspected chronic infection, a maximum difference of 4% in culture yield between the prophylaxis and nonprophylaxis groups was observed. With the use of standard culture techniques, antimicrobial prophylaxis seems to affect cultures in a minority of patients. Along with the known risk of surgical site infections due to inadequate timing of antimicrobial prophylaxis, we discourage the postponement of prophylaxis until tissue samples are obtained in revision surgery. Future studies are necessary to conclude whether the small percentage of false-negative cultures after prophylaxis can be further reduced with the use of more-sensitive culture techniques, like sonication.
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Affiliation(s)
- Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Natividad Benito
- Infectious Diseases Unit, Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alex Soriano
- Service of Infectious Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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Pérez-Prieto D, Portillo ME, Puig-Verdié L, Alier A, Gamba C, Guirro P, Martínez-Díaz S, Horcajada JP, Trampuz A, Monllau JC. Preoperative antibiotic prophylaxis in prosthetic joint infections: not a concern for intraoperative cultures. Diagn Microbiol Infect Dis 2016; 86:442-445. [DOI: 10.1016/j.diagmicrobio.2016.09.014] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 09/20/2016] [Indexed: 10/21/2022]
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15
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Tzeng A, Tzeng TH, Vasdev S, Korth K, Healey T, Parvizi J, Saleh KJ. Treating periprosthetic joint infections as biofilms: key diagnosis and management strategies. Diagn Microbiol Infect Dis 2014; 81:192-200. [PMID: 25586931 DOI: 10.1016/j.diagmicrobio.2014.08.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 08/19/2014] [Accepted: 08/22/2014] [Indexed: 12/23/2022]
Abstract
Considerable evidence suggests that microbial biofilms play an important role in periprosthetic joint infection (PJI) pathogenesis. Compared to free-floating planktonic bacteria, biofilm bacteria are more difficult to culture and possess additional immune-evasive and antibiotic resistance mechanisms, making infections harder to detect and eradicate. This article reviews cutting-edge advances in biofilm-associated infection diagnosis and treatment in the context of current PJI guidelines and highlights emerging technologies that may improve the efficacy and reduce costs associated with PJI. Promising PJI diagnostic tools include culture-independent methods based on sequence comparisons of the bacterial 16S ribosomal RNA gene, which offer higher throughput and greater sensitivity than culture-based methods. For therapy, novel methods based on disrupting biofilm-specific properties include quorum quenchers, bacteriophages, and ultrasound/electrotherapy. Since biofilm infections are not easily detected or treated by conventional approaches, molecular diagnostic techniques and next-generation antibiofilm treatments should be integrated into PJI clinical practice guidelines in the near future.
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Affiliation(s)
- Alice Tzeng
- Koch Institute for Integrative Cancer Research, Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Tony H Tzeng
- Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL 62794-9679, USA
| | - Sonia Vasdev
- Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL 62794-9679, USA
| | - Kyle Korth
- Rush University Medical College, Chicago, IL 60612, USA
| | - Travis Healey
- Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL 62794-9679, USA
| | - Javad Parvizi
- Department of Orthopaedics, Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA
| | - Khaled J Saleh
- Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL 62794-9679, USA.
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