Shoulder Joint Infections with Negative Culture Results: Clinical Characteristics and Treatment Outcomes

The evaluation, classification, and management of septic arthritis of the shoulder: the comprehensive shoulder sepsis system

BACKGROUND

Septic arthritis of the shoulder is distinctly challenging to diagnose and treat. Guidelines for appropriate workup and management are limited and do not account for the variations in clinical presentation. The purpose of this study was to present a comprehensive and anatomically based classification system and treatment algorithm for septic arthritis of the native shoulder joint.

METHODS

A multicenter, retrospective analysis of all patients treated surgically for septic arthritis of the native shoulder joint was performed at 2 tertiary care academic institutions. Preoperative magnetic resonance imaging and operative reports were used to classify patients as having 1 of 3 infection subtypes: type I, confined to the glenohumeral joint; type II, extra-articular extension; or type III, concomitant osteomyelitis. On the basis of these clinical groupings of patients, the comorbidities, types of surgical management, and outcomes were analyzed.

RESULTS

Sixty-five shoulders in 64 patients met the inclusion criteria for the study. Of these infected shoulders, 9.2% had type I infections, 47.7% had type II, and 43.1% had type III. Age and the time between symptom onset and diagnosis were the only significant risk factors for the development of a more severe infection. Fifty-seven percent of shoulder aspirates revealed cell counts below the standard surgical cutoff of 50,000 cells/mL. On average, each patient required 2.2 surgical débridements to eradicate the infection. Infections recurred in 8 shoulders (12.3%). Body mass index was the only risk factor for recurrence of infection. Of the 64 patients, 1 (1.6%) died acutely of sepsis and multiorgan system failure.

CONCLUSION

We propose a comprehensive system for the classification and management of spontaneous shoulder sepsis based on stage and anatomy. Preoperative magnetic resonance imaging can help determine the severity of disease and aid in surgical decision making. A systematic approach to septic arthritis of the shoulder as a unique entity from septic arthritis of other large peripheral joints may lead to more timely diagnosis and treatment and improve the overall prognosis.

Re-operation rates of arthroscopic management versus arthrotomy in treatment of septic arthritis of native shoulder joint in adults. A systematic review and meta-analysis

AIMS

Previous studies have reported concern regarding high reoperation rates when septic arthritis of the native shoulder is treated arthroscopically, compared to open arthrotomy. We aimed to compare re-operation rate between the two strategies.

PATIENTS AND METHODS

The review was registered prospectively at PROSPERO, (CRD42021226518). We searched common databases and references lists (8 February 2021). The inclusion criteria included interventional or observational studies of adult patients with a confirmed diagnosis of native shoulder joint septic arthritis and had either arthroscopy or arthrotomy. The exclusion criteria included patients with periprosthetic or post-surgical infections, patients who had atypical infections, and studies that did not report re-operation rate. Cochrane Collaboration's tool for assessing risk of bias (ROBINS-I) was used.

RESULTS

Nine studies (retrospective cohort studies) were included that involved 5,643 patients (5,645 shoulders). Mean age ranged from 55.6 to 75.5 years, and follow-up time ranged from 1-41 months. Mean duration of symptoms prior to presentation ranged from 8.3-23.3 days. Metanalysis observed a higher re-operation rate for reinfection at any time point following initial arthroscopy in comparison to arthrotomy, odds ratio 2.61 (95% confidence interval 1.04, 6.56). There was marked heterogeneity (I2 = 78.8%) among studies including surgical techniques and missing data.

CONCLUSION

This metanalysis observed a higher reoperation rate in arthroscopy in comparison to arthrotomy for the treatment of native shoulder septic arthritis in adults. The quality of the included evidence is low and the heterogeneity among included studies is marked. Higher quality evidence is still needed that address limitations of previous studies.

Mapping prognostic factors for globe survival in panophthalmitis using logistic regression and Cox proportional hazard models: A retrospective study

Purpose

The aim of this study was to report the outcomes of panophthalmitis and to identify factors significantly affecting globe survival in the disease.

Methods

This was a retrospective study on patients with panophthalmitis in a tertiary hospital between January 1, 2017, and December 31, 2019. The demographics, treatment details, culture results, and final outcomes were recorded. Logistic regression and Cox proportional hazards (CPH) were calculated to identify variables associated with globe loss. A P < 0.05 was considered significant.

Results

Eighty-five eyes of 85 patients (31 culture positive) were eligible for review. The mean age of the participants was 55.21 ± 20.17 years with a male-to-female ratio of 2.04:1. Corneal ulcer (38.82%; n = 33) and open globe injuries (OGIs) (38.82%; n = 33) were the most common etiologies. Pseudomonas aeruginosa (n = 10; 11.76%) was the most common isolate. The mean duration of hospital stay was 7.58 ± 2.32 days. Overall, 44 (51.76%) globes could be salvaged. The need for evisceration (P = 0.901) and hospital stays (P = 0.095) were similar for culture-positive and -negative cohorts. The unadjusted logistic regression and CPH models showed that culture sterility did not affect globe survival [OR = 1.210 (0.501-2.950), P = 0.668; HR = 1.176 (0.617-2.243), P = 0.623]. The adjusted logistic regression and the CPH models showed that corneal ulcers [OR = 10.900 (2.460-48.200), P = 0.002; HR = 5.393 (1.603-18.140), P = 0.006] and OGI [OR = 7.360 (1.650-32.700), P = 0.009; HR = 4.548 (1.321-15.660), P = 0.016] were significantly associated with globe loss.

Conclusion

Corneal ulcer or OGI as the primary etiology is detrimental to globe survival in panophthalmitis.

Septic Olecranon Bursitis With Osteomyelitis Attributed to Cutibacterium acnes: Case Report and Literature Overview of the Dilemma of Potential Contaminants and False-Positives

We report an unusual case of acute septic olecranon bursitis, with probable olecranon osteomyelitis, where the only organism isolated in culture was initially considered a contaminant, Cutibacterium acnes. However, we ultimately considered it the likely causal organism when treatment for most of the other more likely organisms failed. This typically indolent organism is prevalent in pilosebaceous glands, which are scarce in the posterior elbow region. This case illustrates the often challenging empirical management of a musculoskeletal infection when the only organism isolated might be a contaminant, but successful eradication requires continued treatment as if it is the causal organism. The patient is a Caucasian 53-year-old male who presented to our clinic with a second episode of septic bursitis at the same location. Four years prior, he had septic olecranon bursitis from methicillin-sensitive Staphylococcus aureus that was treated uneventfully with one surgical debridement and a one-week course of antibiotics. In the current episode reported here, he sustained a minor abrasion. Cultures were obtained five separate times because of no growth and difficulty eradicating the infection. One culture grew C. acnes on day 21 of incubation; this long duration has been reported. The first several weeks of antibiotic treatment failed to eradicate the infection, which we ultimately attributed to inadequate treatment of C. acnes osteomyelitis. Although C. acnes has a well-known propensity for false-positive cultures as typically reported in post-operative shoulder infections, treatment for our patient's olecranon bursitis/osteomyelitis was successful only after several surgical debridements and a prolonged course of intravenous and oral antibiotics that targeted it as the presumptive causal organism. However, it was possible that C. acnes was a contaminant/superinfection, and another organism was the culprit, such as a Streptococcus or Mycobacterium species that was eradicated by the treatment regime targeted for C. acnes.