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Thompson E, Qureshi A. Pathogens in FRI - Do bugs matter? - An analysis of FRI studies to assess your enemy. J Orthop 2024; 53:59-72. [PMID: 38476676 PMCID: PMC10925936 DOI: 10.1016/j.jor.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 02/09/2024] [Indexed: 03/14/2024] Open
Abstract
Fracture-related infection (FRI) is a devasting complication for both patients and their treating Orthopaedic surgeon that can lead to loss of limb function or even amputation. The unique and unpredictable features of FRI make its diagnosis and treatment a significant challenge. It has substantial morbidity and financial implications for patients, their families and healthcare providers. In this article, we perform an in-depth and comprehensive review of FRI through recent and seminal literature to highlight evolving definitions, diagnostic and treatment approaches, focusing on common pathogens such as Staphylococcus aureus, polymicrobial infections and multi-drug-resistant organisms (MDRO). Furthermore, multiple resistance mechanisms and adaptations for microbial survival are discussed, as well as modern evidence-based medical and surgical advancements in treatment strategies in combating FRI.
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Affiliation(s)
- Emmet Thompson
- Limb Reconstruction Service, Trauma & Orthopaedic Department, University Hospital Southampton, Southampton, UK
| | - Amir Qureshi
- Limb Reconstruction Service, Trauma & Orthopaedic Department, University Hospital Southampton, Southampton, UK
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Wang Y, Xia W, Wang Y, Cui Y, Yu L, Liu C, Zhao D, Guan X, Wang Y, Wu S, Li J, Li Y, Hu J, Liu J. Multiplexed bacterial pathogen detection and clinical characteristics of orthopedic infection in hospitalized patients. Front Cell Infect Microbiol 2024; 14:1394352. [PMID: 38938882 PMCID: PMC11210349 DOI: 10.3389/fcimb.2024.1394352] [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: 03/01/2024] [Accepted: 05/02/2024] [Indexed: 06/29/2024] Open
Abstract
Introduction Accurate identification of the etiology of orthopedic infection is very important for correct and timely clinical management, but it has been poorly studied. In the current study we explored the association of multiple bacterial pathogens with orthopedic infection. Methods Hospitalized orthopedic patients were enrolled in a rural hospital in Qingdao, China. Wound or exudate swab samples were collected and tested for twelve bacterial pathogens with both culture and multiplex real time PCR. Results and discussion A total of 349 hospitalized orthopedic patients were enrolled including 193 cases presenting infection manifestations upon admission and 156 with no sign of infection. Orthopedic infection patients were mainly male (72.5%) with more lengthy hospital stay (median 15 days). At least one pathogen was detected in 42.5% (82/193) of patients with infection while 7.1% (11/156) in the patients without infection (P < 0.001). S. aureus was the most prevalent causative pathogen (15.5%). Quantity dependent pathogen association with infection was observed, particularly for P. aeruginosa and K. pneumoniae, possibly indicating subclinical infection. Most of the patients with detected pathogens had a previous history of orthopedic surgery (odds ratio 2.8, P = 0.038). Pathogen specific clinical manifestations were characterized. Multiplex qPCR, because of its high sensitivity, superior specificity, and powerful quantification could be utilized in combination with culture to guide antimicrobial therapy and track the progression of orthopedic infection during treatment.
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Affiliation(s)
- Yani Wang
- School of Public Health, Qingdao University, Qingdao, China
| | - Wenbo Xia
- Department of Orthopedics, Qingdao Huangdao Traditional Chinese Medicine Hospital, Qingdao, China
| | - Ying Wang
- School of Public Health, Qingdao University, Qingdao, China
| | - Yanxiang Cui
- Department of Clinical Laboratory, Qingdao Huangdao Traditional Chinese Medicine Hospital, Qingdao, China
| | - Linhong Yu
- Qingdao Medical College, Qingdao University, Qingdao, China
| | - Chao Liu
- School of Public Health, Qingdao University, Qingdao, China
| | - Dan Zhao
- School of Public Health, Qingdao University, Qingdao, China
| | - Xiaoxuan Guan
- Department of Clinical Laboratory, Qingdao Huangdao Traditional Chinese Medicine Hospital, Qingdao, China
| | - Yingdi Wang
- School of Public Health, Qingdao University, Qingdao, China
| | - Shanrui Wu
- School of Public Health, Qingdao University, Qingdao, China
| | - Jie Li
- School of Public Health, Qingdao University, Qingdao, China
| | - Yisong Li
- School of Public Health, Qingdao University, Qingdao, China
| | - Jianqiang Hu
- Department of Orthopedics, Qingdao Huangdao Traditional Chinese Medicine Hospital, Qingdao, China
| | - Jie Liu
- School of Public Health, Qingdao University, Qingdao, China
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Jaekel C, Windolf CD, Bieler D, Oezel L, Seiler LF, Lakomek FN, Beyersdorf C, Mertens J, Steuwe A, Windolf J, Grassmann JP. Efficacy of lysostaphin-coated titanium plates on implant-associated MRSA osteitis in minipigs. Eur J Trauma Emerg Surg 2024; 50:887-895. [PMID: 38265442 PMCID: PMC11249774 DOI: 10.1007/s00068-024-02448-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 01/12/2024] [Indexed: 01/25/2024]
Abstract
PURPOSE The growing incidence of implant-associated infections (IAIs) caused by biofilm-forming Staphylococcus aureus in combination with an increasing resistance to antibiotics requires new therapeutic strategies. Lysostaphin has been shown to eliminate this biofilm. Own studies confirm the effectiveness in a murine model. The current study characterizes the effects of lysostaphin-coated plates in an IAI minipig model. METHODS The femur of 30 minipigs was stabilized with a five-hole plate, a bone defect was created, and in 20 cases methicillin-resistant Staphylococcus aureus was applied. Ten animals served as control group. After 14 days, local debridement, lavage, and plate exchange (seven-hole plate) were performed. Ten of the infected minipigs received an uncoated plate and 10 a lysostaphin-coated plate. On day 84, the minipigs were again lavaged, followed by euthanasia. Bacterial load was quantified by colony-forming units (CFU). Immunological response was determined by neutrophils, as well as interleukins. Fracture healing was assessed radiologically. RESULTS CFU showed significant difference between infected minipigs with an uncoated plate and minipigs with a lysostaphin-coated plate (p = 0.0411). The infection-related excessive callus formation and calcification was significantly greater in the infected animals with an uncoated plate than in animals with a lysostaphin-coated plate (p = 0.0164/p = 0.0033). The analysis of polymorphonuclear neutrophils and interleukins did not reveal any pioneering findings. CONCLUSION This study confirms the minipig model for examining IAI. Furthermore, coating of plates using lysostaphin could be a promising tool in the therapeutic strategies of IAI. Future studies should focus on coating technology of implants and on translation into a clinical model.
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Affiliation(s)
- Carina Jaekel
- Department of Orthopaedics and Trauma Surgery, Medical Faculty and University Hospital, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Ceylan D Windolf
- Department of Orthopaedics and Trauma Surgery, Medical Faculty and University Hospital, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Dan Bieler
- Department of Orthopaedics and Trauma Surgery, Medical Faculty and University Hospital, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
- Department of Trauma Surgery and Orthopedics, Reconstructive Surgery, Hand Surgery and Burn Medicine, German Armed Forces Central Hospital Koblenz, Koblenz, Germany
| | - Lisa Oezel
- Department of Orthopaedics and Trauma Surgery, Medical Faculty and University Hospital, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Lars F Seiler
- Department of Orthopaedics and Trauma Surgery, Medical Faculty and University Hospital, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Felix N Lakomek
- Department of Orthopaedics and Trauma Surgery, Medical Faculty and University Hospital, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Christoph Beyersdorf
- Department of Orthopaedics and Trauma Surgery, Medical Faculty and University Hospital, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Jann Mertens
- Department of Trauma Surgery, Orthopaedics and Hand Surgery, Städtisches Klinikum Solingen, Solingen, Germany
| | - Andrea Steuwe
- Department of Diagnostic and Interventional Radiology, Medical Faculty and University Hospital, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Joachim Windolf
- Department of Orthopaedics and Trauma Surgery, Medical Faculty and University Hospital, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Jan P Grassmann
- Department of Trauma, Hand and Reconstructive Surgery, Klinikum Osnabrück GmbH, Osnabrück, Germany
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Woffenden H, Yasen Z, Burden E, Douthwaite A, Elcock SB, Mclean L, Hoven PJV, Fenton P. Fracture-related infection: Analysis of healthcare utilisation and associated costs. Injury 2023; 54:111109. [PMID: 37871348 DOI: 10.1016/j.injury.2023.111109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 09/16/2023] [Accepted: 10/05/2023] [Indexed: 10/25/2023]
Abstract
AIMS A consensus definition of fracture related infection (FRI) has been created with the aim of standardising diagnosis and eliminating heterogeneity that prevents accurate comparison between existing studies. FRI remains one of the most challenging complications in musculoskeletal trauma surgery and carries with it a significant cost burden. A review of UK finances has not been completed utilising consensus diagnostic criteria. The goal of this study was to investigate the hospital-associated healthcare cost related to the treatment of FRI within an NHS major trauma centre. METHOD Through retrospective case-control analysis, 1240 patients with close fractures were identified. Of those, 21 patients with FRI were compared to 63 uninfected patients. Patients were matched based on fracture location, type of procedure and proximity in age. The costs assessed included hospitalisation, imaging, outpatient consultation, pharmaceuticals and procedure charges. Cost data was retrieved from healthcare resource group (HRG) guidelines, NHS Business Service Authority's (NBSA) prescription rates and internal costing. RESULTS The FRI group were found to incur a 2.51 increase in total medial healthcare cost compared to the control group (£22,058 vs £8798 [p < 0.001]), which was primarily due to increased procedural costs (£13,020 vs £6291 [p < 0.001]) and length of hospital stay (£7552 vs £2124 [p < 0.001]). CONCLUSION Whilst diagnosis of FRI has a more rigorous definition following the new consensus, prevalence and cost outcomes are similar to previous studies. Given the deficiency in funding and ongoing challenges of resource allocation to the NHS, it is prudent to incorporate studies such as this into stratifying departmental budgets and quality improvement. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Hugo Woffenden
- Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham B15 2GW, United Kingdom.
| | - Zaid Yasen
- The Royal London Hospital, Whitechapel Rd, London E1 1FR, United Kingdom
| | - Eleanor Burden
- Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham B15 2GW, United Kingdom
| | - Anna Douthwaite
- Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham B15 2GW, United Kingdom
| | - S B Elcock
- Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham B15 2GW, United Kingdom
| | - Lucille Mclean
- Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham B15 2GW, United Kingdom
| | - Peter James von Hoven
- Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham B15 2GW, United Kingdom
| | - Paul Fenton
- Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham B15 2GW, United Kingdom
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Wang Z, Mao H, Xu G. Fibrinogen, albumin-to-globulin ratio, and fibrinogen to albumin-to-globulin ratio may be potential diagnostic biomarkers for infected tibial nonunion. Int Immunopharmacol 2023; 121:110542. [PMID: 37356122 DOI: 10.1016/j.intimp.2023.110542] [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: 04/05/2023] [Revised: 06/02/2023] [Accepted: 06/17/2023] [Indexed: 06/27/2023]
Abstract
AIM The accurate preoperative diagnosis of infected tibial nonunion remains challenging. Hence, we evaluated the diagnostic potential of novel biomarkers for infected tibial nonunion. METHODS This single-center retrospective study was conducted in 252 patients divided into two groups: infected tibial nonunion (67 patients) and aseptic tibial nonunion (185 patients). The preoperative clinical biomarkers included D-dimer, fibrinogen, albumin, globulin, total protein, and C-reactive protein (CRP) levels; albumin-to-globulin ratio (AGR); erythrocyte sedimentation rate (ESR); and white blood cell (WBC) count. Receiver operating characteristic (ROC) curves, sensitivity, and specificity were utilized to compare the biomarkers' diagnostic potential. RESULTS The area under the curve (AUC) values for fibrinogen and AGR were 0.829 and 0.821, respectively, suggesting similarly good diagnostic potentials for infected tibial nonunion. Fibrinogen and AGR were better diagnostic biomarkers for infected tibial nonunion than the WBC count; ESR; D-dimer, albumin, globulin, CRP, and total protein levels, whose AUC values were 0.623, 0.684, 0.741, 0.797, 0.765, 0.715, and 0.554, respectively. The sensitivity and specificity of fibrinogen with a cut-off value of 3.35 g/L were 71.64% and 84.86%, respectively. The corresponding values for AGR with a cut-off value of 1.33 were 73.13% and 86.49%. Moreover, the fibrinogen-AGR (FAGR), i.e., the combination of fibrinogen and AGR, had the highest diagnostic accuracy for infected tibial nonunion (AUC = 0.906). The optimal FAGR cut-off was 2.69, with fair sensitivity (74.63%) but the highest specificity (94.59%). CONCLUSION Fibrinogen, AGR, and FAGR are promising biomarkers for the diagnosis of infected tibial nonunion.
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Affiliation(s)
- Zhen Wang
- Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Haijun Mao
- Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Guangyue Xu
- Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China.
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