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Subedi S, Isler B, Ezure Y, Furuya-Kanamori L, Eriksson L, Paterson DL, Harris PN. Performance characteristics of genus or species-specific Polymerase Chain Reaction (PCR) for the microbial diagnosis of joint infections: A systematic review and meta-analysis. Diagn Microbiol Infect Dis 2024; 110:116422. [PMID: 38981176 DOI: 10.1016/j.diagmicrobio.2024.116422] [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: 02/01/2024] [Revised: 05/20/2024] [Accepted: 07/03/2024] [Indexed: 07/11/2024]
Abstract
Joint infections cause significant morbidity and mortality. Rapid diagnosis enables prompt initiation of appropriate antimicrobial therapy and surgical treatment. We conducted a systematic review and meta-analysis to evaluate the accuracy of genus- or species-specific polymerase chain reaction (PCR) in diagnosing joint infections. The literature databases were searched for articles from January 2010 to December 2022. The meta-analysis using the split component synthesis (SCS) method, included 20 studies with 2,457 adult participants. The pooled sensitivity, specificity, diagnostic odds ratio, and AUC of PCR were 49 % (95 % CI [37.9-60.2]), 95.7 % (95 % CI [91.6-97.8]), 21.32, and 0.82 respectively. Sensitivity was highest for sonicate fluid and lowest for periprosthetic tissue. The mean turnaround time to results was 4.7 hours (SD 1.1). PCR is a favourable option for diagnosing joint infections due to its rapid results, but it has low sensitivity. To enhance diagnostic yield, the test should be used in conjunction with other methods.
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Affiliation(s)
- Shradha Subedi
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Herston, Brisbane, Australia; Sunshine Coast Hospital and Health Service, Queensland, Australia; Microbiology Laboratory, Pathology Queensland, Queensland, Australia.
| | - Burcu Isler
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Herston, Brisbane, Australia; Infection Management Service, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Yukiko Ezure
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Herston, Brisbane, Australia; The School of Public Health, The University of Queensland, Brisbane, Australia
| | - Luis Furuya-Kanamori
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Herston, Brisbane, Australia
| | - Lars Eriksson
- Herston Health Sciences Library, The University of Queensland, Brisbane, Australia
| | - David L Paterson
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Herston, Brisbane, Australia; ADVANCE-ID, Singapore
| | - Patrick Na Harris
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Herston, Brisbane, Australia; Microbiology Laboratory, Pathology Queensland, Queensland, Australia
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2
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Hu H, Ding H, Lyu J, Chen Y, Huang C, Zhang C, Li W, Fang X, Zhang W. Detection of rare microorganisms in bone and joint infections by metagenomic next-generation sequencing. Bone Joint Res 2024; 13:401-410. [PMID: 39142657 PMCID: PMC11324352 DOI: 10.1302/2046-3758.138.bjr-2023-0420.r1] [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] [Indexed: 08/16/2024] Open
Abstract
Aims This aim of this study was to analyze the detection rate of rare pathogens in bone and joint infections (BJIs) using metagenomic next-generation sequencing (mNGS), and the impact of mNGS on clinical diagnosis and treatment. Methods A retrospective analysis was conducted on 235 patients with BJIs who were treated at our hospital between January 2015 and December 2021. Patients were divided into the no-mNGS group (microbial culture only) and the mNGS group (mNGS testing and microbial culture) based on whether mNGS testing was used or not. Results A total of 147 patients were included in the no-mNGS group and 88 in the mNGS group. The mNGS group had a higher detection rate of rare pathogens than the no-mNGS group (21.6% vs 10.2%, p = 0.016). However, the mNGS group had lower rates of antibiotic-related complications, shorter hospital stays, and higher infection control rates compared with the no-mNGS group (p = 0.017, p = 0.003, and p = 0.028, respectively), while there was no significant difference in the duration of antibiotic use (p = 0.957). In culture-negative cases, the mNGS group had lower rates of antibiotic-related complications, shorter hospital stays, and a higher infection control rate than the no-mNGS group (p = 0.036, p = 0.033, p = 0.022, respectively), while there was no significant difference in the duration of antibiotic use (p = 0.748). Conclusion mNGS improves detection of rare pathogens in BJIs. mNGS testing reduces antibiotic-related complications, shortens hospital stay and antibiotic use duration, and improves treatment success rate, benefits which are particularly evident in culture-negative cases.
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Affiliation(s)
- Hongxin Hu
- Department of Orthopaedics, Affiliated Hospital of Putian University, Putian, China
- Department of Orthopedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Orthopedics, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Haiqi Ding
- Department of Orthopedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Orthopedics, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Jianhua Lyu
- Department of Orthopaedics, Affiliated Hospital of Putian University, Putian, China
- Department of Orthopedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Orthopedics, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Yang Chen
- Department of Orthopedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Orthopedics, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Changyu Huang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Orthopedics, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Chaofan Zhang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Orthopedics, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Wenbo Li
- Department of Orthopedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Orthopedics, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Xinyu Fang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Orthopedics, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Wenming Zhang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Orthopedics, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
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Gardete-Hartmann S, Mitterer JA, Sebastian S, Frank BJH, Simon S, Huber S, Löw M, Sommer I, Prinz M, Halabi M, Hofstaetter JG. The role of BioFire Joint Infection Panel in diagnosing periprosthetic hip and knee joint infections in patients with unclear conventional microbiological results. Bone Joint Res 2024; 13:353-361. [PMID: 38981611 PMCID: PMC11233181 DOI: 10.1302/2046-3758.137.bjr-2023-0321.r2] [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: 07/11/2024] Open
Abstract
Aims This study aimed to evaluate the BioFire Joint Infection (JI) Panel in cases of hip and knee periprosthetic joint infection (PJI) where conventional microbiology is unclear, and to assess its role as a complementary intraoperative diagnostic tool. Methods Five groups representing common microbiological scenarios in hip and knee revision arthroplasty were selected from our arthroplasty registry, prospectively maintained PJI databases, and biobank: 1) unexpected-negative cultures (UNCs), 2) unexpected-positive cultures (UPCs), 3) single-positive intraoperative cultures (SPCs), and 4) clearly septic and 5) aseptic cases. In total, 268 archived synovial fluid samples from 195 patients who underwent acute/chronic revision total hip or knee arthroplasty were included. Cases were classified according to the International Consensus Meeting 2018 criteria. JI panel evaluation of synovial fluid was performed, and the results were compared with cultures. Results The JI panel detected microorganisms in 7/48 (14.5%) and 15/67 (22.4%) cases related to UNCs and SPCs, respectively, but not in cases of UPCs. The correlation between JI panel detection and infection classification criteria for early/late acute and chronic PJI was 46.6%, 73%, and 40%, respectively. Overall, the JI panel identified 12.6% additional microorganisms and three new species. The JI panel pathogen identification showed a sensitivity and specificity of 41.4% (95% confidence interval (CI) 33.7 to 49.5) and 91.1% (95% CI 84.7 to 94.9), respectively. In total, 19/195 (9.7%) could have been managed differently and more accurately upon JI panel evaluation. Conclusion Despite its microbial limitation, JI panel demonstrated clinical usefulness by complementing the traditional methods based on multiple cultures, particularly in PJI with unclear microbiological results.
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Affiliation(s)
- Susana Gardete-Hartmann
- Michael Ogon Laboratory for Orthopaedic Research Orthopaedic Hospital Vienna-Speising, Vienna, Austria
| | - Jennyfer A Mitterer
- Michael Ogon Laboratory for Orthopaedic Research Orthopaedic Hospital Vienna-Speising, Vienna, Austria
| | - Sujeesh Sebastian
- Michael Ogon Laboratory for Orthopaedic Research Orthopaedic Hospital Vienna-Speising, Vienna, Austria
| | - Bernhard J H Frank
- Michael Ogon Laboratory for Orthopaedic Research Orthopaedic Hospital Vienna-Speising, Vienna, Austria
| | - Sebastian Simon
- Michael Ogon Laboratory for Orthopaedic Research Orthopaedic Hospital Vienna-Speising, Vienna, Austria
| | - Stephanie Huber
- Michael Ogon Laboratory for Orthopaedic Research Orthopaedic Hospital Vienna-Speising, Vienna, Austria
| | - Marcellino Löw
- Michael Ogon Laboratory for Orthopaedic Research Orthopaedic Hospital Vienna-Speising, Vienna, Austria
| | - Ian Sommer
- Michael Ogon Laboratory for Orthopaedic Research Orthopaedic Hospital Vienna-Speising, Vienna, Austria
| | | | - Milo Halabi
- Institute for Pathology, Microbiology and Molecular Diagnostic, Hospital of the Sisters of Charity, Ried, Austria
| | - Jochen G Hofstaetter
- Michael Ogon Laboratory for Orthopaedic Research Orthopaedic Hospital Vienna-Speising, Vienna, Austria
- 2nd Department, Orthopaedic Hospital Speising, Vienna, Austria
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Ronan EM, Ruff G, Ashkenazi I, Raymond H, Cardillo C, Villa JC, Schwarzkopf R, Aggarwal VK. The Impact of Culture Negativity on the Outcomes of Revision Total Knee Arthroplasty for Chronic PJI. Microorganisms 2024; 12:1384. [PMID: 39065152 PMCID: PMC11278513 DOI: 10.3390/microorganisms12071384] [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: 05/14/2024] [Revised: 06/15/2024] [Accepted: 06/29/2024] [Indexed: 07/28/2024] Open
Abstract
Culture-positive (CP) and culture-negative (CN) periprosthetic joint infections (PJI) remain a crucial area of research; however, current studies comparing these infections rely on unstandardized outcome reporting tools. Our study aimed to compare the outcomes of two-stage revision of CP and CN PJI using the standardized Musculoskeletal Infection Society (MSIS) outcome reporting tool. We retrospectively reviewed 138 patients who were diagnosed with PJI and indicated for two-stage revision total knee arthroplasty (rTKA). The majority of patients in both CP and CN cohorts achieved infection control without the need for reoperation (54.1% and 62.5%, respectively). There was a significant difference in the overall distribution of MSIS outcomes (p = 0.043), with a significantly greater rate of CN patients falling into Tier 1 (infection control without the use of suppressive antibiotics) (52.5% versus 29.6%, p = 0.011). There was also a significant difference in the distribution of septic versus aseptic reoperations after 2nd stage (p = 0.013), with more CP reoperations being septic and more CN reoperations being aseptic. The duration from first to second stage was significantly shorter in the CN cohort (p = 0.002). While overall infection control was similar between cohorts, these data suggest that the outcomes of two-stage rTKA are favorable in cases of CN PJI.
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Affiliation(s)
| | | | | | | | | | | | - Ran Schwarzkopf
- NYU Langone Health, New York, NY 10003, USA; (E.M.R.); (I.A.); (H.R.); (C.C.); (J.C.V.); (V.K.A.)
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Schaffler BC, Longwell M, Byers B, Kreft R, Ramot R, Ramot Y, Schwarzkopf R. Nanoparticle ultrasonication outperforms conventional irrigation solutions in eradicating Staphylococcus aureus biofilm from titanium surfaces: an in vitro study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:2729-2734. [PMID: 38761198 DOI: 10.1007/s00590-024-03982-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 04/29/2024] [Indexed: 05/20/2024]
Abstract
PURPOSE Bacterial biofilms create a challenge in the treatment of prosthetic joint infection (PJI), and failure to eradicate biofilms is often implicated in the high rates of recurrence. In this study, we aimed to compare the effectiveness of a novel nanoparticle ultrasonication technology on Staphylococcus aureus biofilm eradication compared to commonly used orthopedic irrigation solutions. METHODS Twenty-four sterile, titanium alloy discs were inoculated with a standardized concentration of methicillin-resistant S. aureus and cultured for seven days to allow for biofilm formation. Discs were then treated with either ultrasonicated nanoparticle therapy or irrigation with chlorhexidine gluconate, povidone-iodine or normal saline. The remaining bacteria on each surface was subsequently plated for colony-forming units of S. aureus. Bacterial eradication was reported as a decrease in CFUs relative to the control group. Mann-Whitney U tests were used to compare between groups. RESULTS Treatment with ultrasonicated nanoparticles resulted in a significant mean decrease in CFUs of 99.3% compared to controls (p < 0.0001). Irrigation with povidone-iodine also resulted in a significant 77.5% reduction in CFUs compared to controls (p < 0.0001). Comparisons between ultrasonicated nanoparticles and povidone-iodine demonstrated a significantly higher reduction in bacterial CFUs in the nanoparticle group (p < 0.0001). CONCLUSION Ultrasonicated nanoparticle were superior to commonly used bactericidal irrigation solutions in the eradication of S. aureus from a titanium surface. Future clinical studies are warranted to evaluate this ultrsonication technology in the treatment of PJI.
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Affiliation(s)
- Benjamin C Schaffler
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, 301 East 17Th Street, New York, NY, 10003, USA
| | - Mark Longwell
- Center for Excellence in Biofilm Research, Allegheny Health Network Research Institute, Pittsburgh, PA, USA
| | - Barbara Byers
- Center for Excellence in Biofilm Research, Allegheny Health Network Research Institute, Pittsburgh, PA, USA
| | - Rachel Kreft
- Center for Excellence in Biofilm Research, Allegheny Health Network Research Institute, Pittsburgh, PA, USA
| | - Roi Ramot
- Center for Excellence in Biofilm Research, Allegheny Health Network Research Institute, Pittsburgh, PA, USA
| | - Yair Ramot
- Center for Excellence in Biofilm Research, Allegheny Health Network Research Institute, Pittsburgh, PA, USA
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, 301 East 17Th Street, New York, NY, 10003, USA.
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Mikziński P, Kraus K, Widelski J, Paluch E. Modern Microbiological Methods to Detect Biofilm Formation in Orthopedy and Suggestions for Antibiotic Therapy, with Particular Emphasis on Prosthetic Joint Infection (PJI). Microorganisms 2024; 12:1198. [PMID: 38930580 PMCID: PMC11205407 DOI: 10.3390/microorganisms12061198] [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: 05/12/2024] [Revised: 06/05/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024] Open
Abstract
Biofilm formation is a serious problem that relatively often causes complications in orthopedic surgery. Biofilm-forming pathogens invade implanted foreign bodies and surrounding tissues. Such a condition, if not limited at the appropriate time, often requires reoperation. This can be partially prevented by selecting an appropriate prosthesis material that prevents the development of biofilm. There are many modern techniques available to detect the formed biofilm. By applying them we can identify and visualize biofilm-forming microorganisms. The most common etiological factors associated with biofilms in orthopedics are: Staphylococcus aureus, coagulase-negative Staphylococci (CoNS), and Enterococcus spp., whereas Gram-negative bacilli and Candida spp. also deserve attention. It seems crucial, for therapeutic success, to eradicate the microorganisms able to form biofilm after the implantation of endoprostheses. Planning the effective targeted antimicrobial treatment of postoperative infections requires accurate identification of the microorganism responsible for the complications of the procedure. The modern microbiological testing techniques described in this article show the diagnostic options that can be followed to enable the implementation of effective treatment.
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Affiliation(s)
- Paweł Mikziński
- Faculty of Medicine, Wroclaw Medical University, Wyb. Pasteura 1, 50-376 Wroclaw, Poland; (P.M.); (K.K.)
| | - Karolina Kraus
- Faculty of Medicine, Wroclaw Medical University, Wyb. Pasteura 1, 50-376 Wroclaw, Poland; (P.M.); (K.K.)
| | - Jarosław Widelski
- Department of Pharmacognosy with Medicinal Plants Garden, Lublin Medical University, 20-093 Lublin, Poland;
| | - Emil Paluch
- Department of Microbiology, Faculty of Medicine, Wroclaw Medical University, Tytusa Chalubinskiego 4, 50-376 Wroclaw, Poland
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7
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Azad MA, Patel R. Practical Guidance for Clinical Microbiology Laboratories: Microbiologic diagnosis of implant-associated infections. Clin Microbiol Rev 2024; 37:e0010423. [PMID: 38506553 PMCID: PMC11237642 DOI: 10.1128/cmr.00104-23] [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] [Indexed: 03/21/2024] Open
Abstract
SUMMARYImplant-associated infections (IAIs) pose serious threats to patients and can be associated with significant morbidity and mortality. These infections may be difficult to diagnose due, in part, to biofilm formation on device surfaces, and because even when microbes are found, their clinical significance may be unclear. Despite recent advances in laboratory testing, IAIs remain a diagnostic challenge. From a therapeutic standpoint, many IAIs currently require device removal and prolonged courses of antimicrobial therapy to effect a cure. Therefore, making an accurate diagnosis, defining both the presence of infection and the involved microorganisms, is paramount. The sensitivity of standard microbial culture for IAI diagnosis varies depending on the type of IAI, the specimen analyzed, and the culture technique(s) used. Although IAI-specific culture-based diagnostics have been described, the challenge of culture-negative IAIs remains. Given this, molecular assays, including both nucleic acid amplification tests and next-generation sequencing-based assays, have been used. In this review, an overview of these challenging infections is presented, as well as an approach to their diagnosis from a microbiologic perspective.
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Affiliation(s)
- Marisa Ann Azad
- Division of Infectious Diseases, Department of Medicine, The Ottawa Hospital, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Robin Patel
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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8
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Janz V, Rakow A, Schröder L, Hofer A, Wiebe S, Schoon J, Weiss S, Bröker BM, Wassilew GI, Raafat D. Investigation of the pathogen-specific antibody response in periprosthetic joint infection. Infection 2024:10.1007/s15010-024-02285-y. [PMID: 38819638 DOI: 10.1007/s15010-024-02285-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 04/24/2024] [Indexed: 06/01/2024]
Abstract
PURPOSE Periprosthetic joint infections (PJIs) are a very demanding complication of arthroplasty. Diagnosis of PJI and pathogen identification pose considerable challenges in clinical practice. We hypothesized that the pathogen-specific immune response to PJI reflects the infection process, provides clinically relevant information on disease course, and has the potential to further optimize antimicrobial therapy. METHODS We conducted a prospective matched cohort pilot study with 13 patients undergoing two-stage septic revision arthroplasty (PJI patients) between 06/2020 and 06/2021, as well as 11 control patients undergoing one-stage aseptic revision arthroplasty (Non-PJI patients). Pre-, intra- and postoperative serum samples were collected at standardized time points. We developed a custom Luminex®-based quantitative bead-based suspension array (Infection Array; IA), and used it for simultaneous measurement of antibody specificities against 32 pathogens commonly associated with PJI in 267 serum samples. RESULTS The IA was able to trace the dynamics of the pathogen-specific humoral immune response in all patients against PJI-related pathogens, prominently coagulase-negative staphylococci and streptococci. Pathogen-specific serum antibody titers declined in 62% of PJI patients over the course of treatment, while no changes in antibody titers were observed in 82% of Non-PJI patients during this study. Our serological data strongly suggested that antibody signatures reflect an immune response to microbial invasion. CONCLUSION Our results provide insights into the pathophysiology of PJI and information on the individual disease courses. The IA is therefore a promising and novel serological tool of high resolution for monitoring the immunoproteomic footprints of infectious pathogens in the course of PJI.
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Affiliation(s)
- Viktor Janz
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, 17475, Greifswald, Germany
- Sporthopaedicum, 93053, Regensburg, Germany
| | - Anastasia Rakow
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, 17475, Greifswald, Germany
| | - Leonie Schröder
- Institute of Immunology, University Medicine Greifswald, 17475, Greifswald, Germany
| | - André Hofer
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, 17475, Greifswald, Germany
| | - Sergej Wiebe
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, 17475, Greifswald, Germany
| | - Janosch Schoon
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, 17475, Greifswald, Germany
| | - Stefan Weiss
- Interfaculty Institute for Genetics and Functional Genomics, University Medicine Greifswald, 17475, Greifswald, Germany
| | - Barbara M Bröker
- Institute of Immunology, University Medicine Greifswald, 17475, Greifswald, Germany
| | - Georgi I Wassilew
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, 17475, Greifswald, Germany
| | - Dina Raafat
- Institute of Immunology, University Medicine Greifswald, 17475, Greifswald, Germany.
- Department of Microbiology and Immunology, Faculty of Pharmacy, Alexandria University, 21521, Alexandria, Egypt.
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9
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Osborn LJ, Fissel J, Gomez S, Mestas J, Flores-Vazquez J, Lee J, Hakimjavadi H, Costales C, Dien Bard J. Development of an automated amplicon-based next-generation sequencing pipeline for rapid detection of bacteria and fungi directly from clinical specimens. J Clin Microbiol 2024; 62:e0174923. [PMID: 38624235 PMCID: PMC11077995 DOI: 10.1128/jcm.01749-23] [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: 12/29/2023] [Accepted: 03/23/2024] [Indexed: 04/17/2024] Open
Abstract
The timely identification of microbial pathogens is essential to guide targeted antimicrobial therapy and ultimately, successful treatment of an infection. However, the yield of standard microbiology testing (SMT) is directly related to the duration of antecedent antimicrobial therapy as SMT culture methods are dependent on the recovery of viable organisms, the fastidious nature of certain pathogens, and other pre-analytic factors. In the last decade, metagenomic next-generation sequencing (mNGS) has been successfully utilized as a diagnostic tool for various applications within the clinical laboratory. However, mNGS is resource, time, and labor-intensive-requiring extensive laborious preliminary benchwork, followed by complex bioinformatic analysis. We aimed to address these shortcomings by developing a largely Automated targeted Metagenomic next-generation sequencing (tmNGS) PipeLine for rapId inFectIous disEase Diagnosis (AMPLIFIED) to detect bacteria and fungi directly from clinical specimens. Therefore, AMPLIFIED may serve as an adjunctive approach to complement SMT. This tmNGS pipeline requires less than 1 hour of hands-on time before sequencing and less than 2 hours of total processing time, including bioinformatic analysis. We performed tmNGS on 50 clinical specimens with concomitant cultures to assess feasibility and performance in the hospital laboratory. Of the 50 specimens, 34 (68%) were from true clinical infections. Specimens from cases of true infection were more often tmNGS positive compared to those from the non-infected group (82.4% vs 43.8%, respectively, P = 0.0087). Overall, the clinical sensitivity of AMPLIFIED was 54.6% with 85.7% specificity, equating to 70.6% and 75% negative and positive predictive values, respectively. AMPLIFIED represents a rapid supplementary approach to SMT; the typical time from specimen receipt to identification of potential pathogens by AMPLIFIED is roughly 24 hours which is markedly faster than the days, weeks, and months required to recover bacterial, fungal, and mycobacterial pathogens by culture, respectively. IMPORTANCE To our knowledge, this represents the first application of an automated sequencing and bioinformatics pipeline in an exclusively pediatric population. Next-generation sequencing is time-consuming, labor-intensive, and requires experienced personnel; perhaps contributing to hesitancy among clinical laboratories to adopt such a test. Here, we report a strong case for use by removing these barriers through near-total automation of our sequencing pipeline.
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Affiliation(s)
- Lucas J. Osborn
- Department of Pathology and Laboratory Medicine, Children’s Hospital Los Angeles, Los Angeles, California, USA
| | - John Fissel
- Department of Pathology and Laboratory Medicine, Children’s Hospital Los Angeles, Los Angeles, California, USA
| | - Samantha Gomez
- Department of Pathology and Laboratory Medicine, Children’s Hospital Los Angeles, Los Angeles, California, USA
| | - Javier Mestas
- Department of Pathology and Laboratory Medicine, Children’s Hospital Los Angeles, Los Angeles, California, USA
| | - Jessica Flores-Vazquez
- Department of Pathology and Laboratory Medicine, Children’s Hospital Los Angeles, Los Angeles, California, USA
| | - Jaehyeon Lee
- Department of Pathology and Laboratory Medicine, Children’s Hospital Los Angeles, Los Angeles, California, USA
- Department of Laboratory Medicine, Jeonbuk National University Medical School and Hospital, Jeonju, Jeollabukdo, South Korea
| | - Hesamedin Hakimjavadi
- Department of Pathology and Laboratory Medicine, Children’s Hospital Los Angeles, Los Angeles, California, USA
| | - Cristina Costales
- Department of Pathology and Laboratory Medicine, Children’s Hospital Los Angeles, Los Angeles, California, USA
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jennifer Dien Bard
- Department of Pathology and Laboratory Medicine, Children’s Hospital Los Angeles, Los Angeles, California, USA
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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10
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Straub J, Staats K, Vertesich K, Kowalscheck L, Windhager R, Böhler C. Two-stage revision for periprosthetic joint infection after hip and knee arthroplasty. Bone Joint J 2024; 106-B:372-379. [PMID: 38555938 DOI: 10.1302/0301-620x.1064.bjj-2023-0638.r2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Aims Histology is widely used for diagnosis of persistent infection during reimplantation in two-stage revision hip and knee arthroplasty, although data on its utility remain scarce. Therefore, this study aims to assess the predictive value of permanent sections at reimplantation in relation to reinfection risk, and to compare results of permanent and frozen sections. Methods We retrospectively collected data from 226 patients (90 hips, 136 knees) with periprosthetic joint infection who underwent two-stage revision between August 2011 and September 2021, with a minimum follow-up of one year. Histology was assessed via the SLIM classification. First, we analyzed whether patients with positive permanent sections at reimplantation had higher reinfection rates than patients with negative histology. Further, we compared permanent and frozen section results, and assessed the influence of anatomical regions (knee versus hip), low- versus high-grade infections, as well as first revision versus multiple prior revisions on the histological result at reimplantation. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), chi-squared tests, and Kaplan-Meier estimates were calculated. Results Overall, the reinfection rate was 18%. A total of 14 out of 82 patients (17%) with positive permanent sections at reimplantation experienced reinfection, compared to 26 of 144 patients (18%) with negative results (p = 0.996). Neither permanent sections nor fresh frozen sections were significantly associated with reinfection, with a sensitivity of 0.35, specificity of 0.63, PPV of 0.17, NPV of 0.81, and accuracy of 58%. Histology was not significantly associated with reinfection or survival time for any of the analyzed sub-groups. Permanent and frozen section results were in agreement for 91% of cases. Conclusion Permanent and fresh frozen sections at reimplantation in two-stage revision do not serve as a reliable predictor for reinfection.
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Affiliation(s)
- Jennifer Straub
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Kevin Staats
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Klemens Vertesich
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Lars Kowalscheck
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Reinhard Windhager
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Christoph Böhler
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
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11
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Lu H, Wang W, Xu H, Zhou K, Zhou Z. Efficacy and safety of two-stage revision for patients with culture-negative versus culture-positive periprosthetic joint infection: a single-center retrospective study. BMC Musculoskelet Disord 2024; 25:160. [PMID: 38378509 PMCID: PMC10877912 DOI: 10.1186/s12891-024-07259-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 02/04/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND The safety and efficacy of two-stage revision for culture-negative PJI remain controversial. This study analyzed outcomes after two-stage revision in patients with culture-negative and culture-positive periprosthetic joint infection (PJI) during follow-up lasting at least two years. METHODS Data were retrospectively analysed patients who underwent hip or knee revision arthroplasty from January 2008 to October 2020 at our medical center. The primary outcome was the re-revision rate, while secondary outcomes were the rates of reinfection, readmission, and mortality. Patients with culture-negative or culture-positive PJI were compared in terms of these outcomes, as well as survival time without reinfection or revision surgery, based on Kaplan‒Meier analysis. RESULTS The final analysis included 87 patients who were followed up for a mean of 72.3 months (range, 24-123 months). The mean age was 58.1 years in the culture-negative group (n = 24) and 59.1 years in the culture-positive group (n = 63). The two groups (culture-negative versus culture-positive) did not differ significantly in rates of re-revision (0.0% vs. 3.2%, p > 0.05), reinfection (4.2% vs. 3.2%, p > 0.05), readmission (8.4% vs. 8.0%, p > 0.05), or mortality (8.3% vs. 7.9%, p > 0.05). They were also similar in survival rates without infection-related complications or revision surgery at 100 months (91.5% in the culture-negative group vs. 87.9% in the culture-positive group; Mantel‒Cox log-rank χ2 = 0.251, p = 0.616). CONCLUSION The two-stage revision proves to be a well-tolerated and effective procedure in both culture-negative and culture-positive PJI during mid to long-term follow-up.
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Affiliation(s)
- Hanpeng Lu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Wenqi Wang
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Hong Xu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Kai Zhou
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Zongke Zhou
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China.
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12
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Ramos MT, Chang G, Wilson C, Gilbertie J, Krieg J, Parvizi J, Chen AF, Otto CM, Schaer TP. Dogs can detect an odor profile associated with Staphylococcus aureus biofilms in cultures and biological samples. FRONTIERS IN ALLERGY 2024; 5:1275397. [PMID: 38414670 PMCID: PMC10896932 DOI: 10.3389/falgy.2024.1275397] [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: 08/09/2023] [Accepted: 01/23/2024] [Indexed: 02/29/2024] Open
Abstract
Introduction The study investigated the utilization of odor detection dogs to identify the odor profile of Staphylococcus aureus (S. aureus) biofilms in pure in vitro samples and in in vivo biosamples from animals and humans with S. aureus periprosthetic joint infection (PJI). Biofilms form when bacterial communities aggregate on orthopedic implants leading to recalcitrant infections that are difficult to treat. Identifying PJI biofilm infections is challenging, and traditional microbiological cultures may yield negative results even in the presence of clinical signs. Methods Dogs were trained on pure in vitro S. aureus biofilms and tested on lacrimal fluid samples from an in vivo animal model (rabbits) and human patients with confirmed S. aureus PJI. Results The results demonstrated that dogs achieved a high degree of sensitivity and specificity in detecting the odor profile associated with S. aureus biofilms in rabbit samples. Preliminary results suggest that dogs can recognize S. aureus volatile organic compounds (VOCs) in human lacrimal fluid samples. Discussion Training odor detection dogs on in vitro S. aureus, may provide an alternative to obtaining clinical samples for training and mitigates biosecurity hazards. The findings hold promise for culture-independent diagnostics, enabling early disease detection, and improved antimicrobial stewardship. In conclusion, this research demonstrates that dogs trained on in vitro S. aureus samples can identify the consistent VOC profile of PJI S. aureus biofilm infections. The study opens avenues for further investigations into a retained VOC profile of S. aureus biofilm infection. These advancements could revolutionize infectious disease diagnosis and treatment, leading to better patient outcomes and addressing the global challenge of antimicrobial resistance.
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Affiliation(s)
- Meghan T Ramos
- Penn Vet Working Dog Center, Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Gerard Chang
- Department of Orthopaedics, Geisel School of Medicine at Dartmouth, Lebanon, NH, United States
| | - Clara Wilson
- Penn Vet Working Dog Center, Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Jessica Gilbertie
- Center for One Health Research Edward Via College of Osteopathic Medicine, Blacksburg, VA, United States
| | - James Krieg
- Rothman Orthopaedic Institute, Philadelphia, PA, United States
| | - Javad Parvizi
- Rothman Orthopaedic Institute, Philadelphia, PA, United States
| | - Antonia F Chen
- Department of Orthopaedics, Harvard Medical School, Brigham and Women's Hospital, Harvard University, Boston, MA, United States
| | - Cynthia M Otto
- Penn Vet Working Dog Center, Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Thomas P Schaer
- Department of Clinical Studies New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA, United States
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13
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Lai YH, Xu H, Li XY, Zhao WX, Lv N, Zhou ZK. Outcomes of culture-negative or -positive periprosthetic joint infections: A systematic review and meta-analysis. Jt Dis Relat Surg 2024; 35:231-241. [PMID: 38108185 PMCID: PMC10746900 DOI: 10.52312/jdrs.2023.1437] [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: 10/15/2023] [Accepted: 10/30/2023] [Indexed: 12/19/2023] Open
Abstract
OBJECTIVES This study overviewed the current database of studies on periprosthetic joint infections (PJIs) to compare outcomes and antibiotic side effects in culture-negative or culture-positive PJIs and assess treatment options for culture-negative PJIs. PATIENTS AND METHODS A systematic review and meta-analysis was undertaken using studies published before July 2022 in MEDLINE, EMBASE, and Cochrane Library. All studies comparing treatment of culture-negative or -positive PJIs were included. Afterward, the infection control rate, periprosthetic or spacer fracture, hip joint or spacer dislocation, and antibiotic side effects in different treatment methods of PJI were analyzed. RESULTS Eleven studies involving 1,747 patients were included. Most studies clearly defined the infection control criteria: no pain or swelling, no wound drainage, normal serology, and normal radiographic findings. Patients were followed until treatment failure, death, or until the last clinical visit without evidence of treatment failure. The two types of PJIs did not differ significantly in infection control rates (culture-negative PJI 79.2% vs. culture-positive PJI 76.6%; odds ratio [OR]=1.20, 95% confidence interval [CI]: 0.84 to 1.70), either after all types of surgical treatment or after two-stage revision arthroplasty (OR=1.12, 95% CI: 0.72 to 1.75), single-stage revision arthroplasty (OR=0.51, 95% CI: 0.19 to 1.37), or debridement, antibiotics, and implant retention (OR=0.88, 95% CI: 0.50 to 1.54). Similarly, we did not find differences in periprosthetic or spacer fracture and hip joint or spacer dislocation. For culture-negative PJIs, the infection control rate was 85.2% after two-stage revision arthroplasty, 90.6% after single-stage revision arthroplasty, and 69.7% after debridement, antibiotics, and implant retention. Data pooled from three studies showed higher incidence of antibiotic side effects for culture-negative PJIs. CONCLUSION The clinical outcomes of one-stage revision and two-stage revision are comparable. Therefore, both of them can be considered in surgical treatment for culture-negative PJIs. In addition, limited data showed a higher incidence of antibiotic side effects in culture-negative PJIs.
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Affiliation(s)
| | | | | | | | | | - Zong-Ke Zhou
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, 610041 China.
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14
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Ramos MS, Pasqualini I, Surace PA, Molloy RM, Deren ME, Piuzzi NS. Arthrofibrosis After Total Knee Arthroplasty: A Critical Analysis Review. JBJS Rev 2023; 11:01874474-202312000-00001. [PMID: 38079496 DOI: 10.2106/jbjs.rvw.23.00140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
» Arthrofibrosis after total knee arthroplasty (TKA) is the new formation of excessive scar tissue that results in limited ROM, pain, and functional deficits.» The diagnosis of arthrofibrosis is based on the patient's history, clinical examination, absence of alternative diagnoses from diagnostic testing, and operative findings. Imaging is helpful in ruling out specific causes of stiffness after TKA. A biopsy is not indicated, and no biomarkers of arthrofibrosis exist.» Arthrofibrosis pathophysiology is multifactorial and related to aberrant activation and proliferation of myofibroblasts that primarily deposit type I collagen in response to a proinflammatory environment. Transforming growth factor-beta signaling is the best established pathway involved in arthrofibrosis after TKA.» Management includes both nonoperative and operative modalities. Physical therapy is most used while revision arthroplasty is typically reserved as a last resort. Additional investigation into specific pathophysiologic mechanisms can better inform targeted therapeutics.
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Affiliation(s)
- Michael S Ramos
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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15
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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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16
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Crowe M, Giacobazzi M, Griffin E, Storm S. Borrelia burgdorferi-A Bacterium Worthy of Consideration in Culture-Negative Prosthetic Joint Infection. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202309000-00009. [PMID: 37707984 PMCID: PMC10503676 DOI: 10.5435/jaaosglobal-d-23-00068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/14/2023] [Accepted: 08/04/2023] [Indexed: 09/16/2023]
Abstract
A 68-year-old woman presented to the orthopaedic office with 2 weeks of atraumatic right prosthetic knee pain and swelling. She previously lived pain free and fully functional after a total knee arthroplasty 8 years ago. Initial radiographs showed a small joint effusion, and serum inflammatory markers were elevated. Arthrocentesis yielded 12ccs of culture-negative cloudy serous fluid containing 3,270 white blood cells, 92% polymorphonuclear neutrophils. The patient underwent prosthesis explant, antibiotic spacer placement, and began empiric IV antibiotic therapy as stage one of a planned two-stage revision. Intraoperative tissue cultures were negative, and the postoperative plan was to continue IV vancomycin for a total of 6 weeks. Two weeks post-op, serum Lyme antibody testing returned positive. The patient was switched to doxycycline and ceftriaxone for a total duration of 4 weeks, followed by a successful second-stage revision and remains asymptomatic after 1 year. Five cases of culture-negative prosthetic joint infections caused by the spirochete, Borrelia burgdorferi, have been reported in the orthopaedic literature.1-4 We present a sixth case, occurring in a 68-year-old woman in Northwestern Pennsylvania, 8 years after a primary right total knee arthroplasty.
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Affiliation(s)
- Mary Crowe
- From the Lake Erie College of Osteopathic Medicine, Erie, PA
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17
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Hantouly AT, Alzobi O, Toubasi AA, Zikria B, Al Dosari MAA, Ahmed G. Higher sensitivity and accuracy of synovial next-generation sequencing in comparison to culture in diagnosing periprosthetic joint infection: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2023; 31:3672-3683. [PMID: 36244018 PMCID: PMC10435641 DOI: 10.1007/s00167-022-07196-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/02/2022] [Indexed: 12/29/2022]
Abstract
PURPOSE The purpose of this meta-analysis was to compare the diagnostic parameters of synovial next-generation sequencing (NGS) and cultures in diagnosing periprosthetic joint infections (PJI). METHODS PubMed, Web of Science, Cochrane, and Google Scholar were searched from inception until 8 Jan 2022 for literature investigating the role of NGS in comparison to culture in the diagnosis of PJI. The studies were included if they investigated the diagnostic value of culture and NGS in diagnosing PJIs against the Musculoskeletal Infection Society (MSIS) criteria. Diagnostic parameters, such as sensitivity, specificity, positive predictive value, negative predictive value, positive-likelihood ratio, negative-likelihood ratio, accuracy, and area under the curve (AUC), were calculated for the included studies to evaluate the performance of NGS in comparison to culture in PJI diagnosis. RESULTS The total number of the included patients was 341 from seven articles. The pooled sensitivity, specificity, and diagnostic odds ratio of NGS were 94% (95% CI 91-97%), 89% (95% CI 82-95%), and 138.5 (95% CI 49.1-390.5), respectively. NGS has positive- and negative-likelihood ratios of 7.9 (95% CI 3.99-15.6) and 0.1 (95% CI 0.0-0.1), respectively. On the other hand, the pooled sensitivity, specificity, and diagnostic odds ratio of culture were 70% (95% CI 61-79%), 94% (95% CI 88-98%), and 28.0 (95% CI 12.6-62.2), respectively. The SROC curve for NGS showed that the accuracy (AUC) was 91.9%, and that the positive and negative predictive values were 8.6 (95% CI 5.0-19.5) and 0.1 (95% CI 0.0-0.1), respectively. While, culture SROC curve demonstrated that the accuracy (AUC) was 80.5% and the positive- and negative-likelihood ratio were 12.1 (95% CI 4.5-49.6) and 0.3 (95% CI 0.2-0.4). CONCLUSIONS NGS has a potential role in diagnosing hip and knee PJIs due to its high sensitivity, specificity, and accuracy. However, the sensitivity and specificity reported by the studies varied according to the time of synovial sampling (preoperative, postoperative, or mixed).
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Affiliation(s)
- Ashraf T Hantouly
- Department of Orthopedic Surgery, Surgical Specialty Center, Hamad Medical Corporation, Doha, Qatar
| | - Osama Alzobi
- Department of Orthopedic Surgery, Surgical Specialty Center, Hamad Medical Corporation, Doha, Qatar
| | | | - Bashir Zikria
- Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
| | | | - Ghalib Ahmed
- Department of Orthopedic Surgery, Surgical Specialty Center, Hamad Medical Corporation, Doha, Qatar.
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18
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Lara-Taranchenko Y, Corona PS, Rodríguez-Pardo D, Salmerón-Menéndez P, Vicente Ciurans M, García-Martínez MC, Carrera Calderer L. Prosthetic joint infection caused by an atypical gram-negative bacilli: Odoribactersplanchnicus. Anaerobe 2023; 82:102740. [PMID: 37315915 DOI: 10.1016/j.anaerobe.2023.102740] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 05/05/2023] [Accepted: 05/11/2023] [Indexed: 06/16/2023]
Abstract
Prosthetic joint infection (PJI) is a devastating complication after total hip arthroplasty. Its management consists of both: a radical debridement and implant retention or exchange (depending on the timing of symptoms) and directed antibiotic therapy. Thus, the isolation of atypical microorganisms implies a challenge, where anaerobes are responsible for only 4% of cases. However, Odoribacter splanchnicus has not been reported as a cause of PJI yet. We present an 82 year-old woman who was diagnosed with hip PJI. A radical debridement, prosthetic withdrawal, and spacer introduction was performed. Despite the directed antibiotic therapy against E. coli which was first isolated, the patient persisted clinically febrile. An anaerobic Gram-negative rod was isolated and finally, Odoribacter splanchnicus was identified and confirmed by 16S rRNA gene sequencing. Then, antibiotic bitherapy with ciprofloxacin and metronidazole was started until 6 weeks after surgery. The patient had no signs of infection recurrence after then. This case report also shows the importance of genomic identification of rare microorganisms causing PJI, and also allows setting a directed antibiotic therapy which is crucial for infection eradication.
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Affiliation(s)
- Yuri Lara-Taranchenko
- Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona, Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Pablo S Corona
- Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona, Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Dolors Rodríguez-Pardo
- Infectious Diseases Department, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona, Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Paula Salmerón-Menéndez
- Microbiology Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Marina Vicente Ciurans
- Microbiology Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | | | - Lluís Carrera Calderer
- Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona, Vall d'Hebron 119-129, 08035, Barcelona, Spain.
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19
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Mozella ADP, Assunção TND, Cobra HADAB, Minamoto STN, Salim R, Leal AC. Microbiological Profile of Periprosthetic Knee Infections in a Brazilian Unified Health System Hospital Specialized in Highly Complex Orthopedic Surgeries. Rev Bras Ortop 2023; 58:443-448. [PMID: 37396091 PMCID: PMC10310415 DOI: 10.1055/s-0042-1758368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 09/12/2022] [Indexed: 07/04/2023] Open
Abstract
Objective We studied the microbiological profile of periprosthetic knee infections treated in a Brazilian tertiary hospital. Methods The study included all patients undergoing revision surgery for total knee arthroplasty (RTKA) between November 2019 and December 2021, with a diagnosis of periprosthetic infection confirmed per the 2018 International Consensus Meeting (ICM) criteria. Results Sixty-two patients had a periprosthetic joint infection (PJI) per the 2018 ICM criteria. Cultures were monomicrobial in 79% and polymicrobial in 21% of cases. The most frequent bacterium in microbiological tissue and synovial fluid cultures was Staphylococcus aureus , observed in 26% of PJI patients. Periprosthetic joint infection with negative cultures occurred in 23% of patients. Conclusion Our results show the following: i) a high prevalence of Staphylococcus as an etiological agent for knee PJI; ii) a high incidence of polymicrobial infections in early infections; iii) the occurrence of PJI with negative cultures in approximately one fourth of the subjects.
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Affiliation(s)
- Alan de Paula Mozella
- Centro de Cirurgia do Joelho, Instituto Nacional de Traumatologia e Ortopedia (INTO), Rio de Janeiro, RJ, Brasil
| | - Thales Nunes de Assunção
- Centro de Cirurgia do Joelho, Instituto Nacional de Traumatologia e Ortopedia (INTO), Rio de Janeiro, RJ, Brasil
| | | | - Sandra Tie Nishibe Minamoto
- Centro de Cirurgia do Joelho, Instituto Nacional de Traumatologia e Ortopedia (INTO), Rio de Janeiro, RJ, Brasil
| | - Rodrigo Salim
- Departamento de Ortopedia e Anestesiologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP-RP), São Paulo, SP, Brasil
| | - Ana Carolina Leal
- Divisão de Ensino e Pesquisa, Instituto Nacional de Traumatologia e Ortopedia (INTO), Rio de Janeiro, RJ, Brasil
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20
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Sculco P, Kapadia M, Moezinia CJ, Mannstadt I, Miller AO, Donlin L, Henry M, Russell L, Figgie M, Nocon A, Pannellini T, Goodman SM. Clinical and Histological Features of Prosthetic Joint Infections May Differ in Patients With Inflammatory Arthritis and Osteoarthritis. HSS J 2023; 19:146-153. [PMID: 37065104 PMCID: PMC10090847 DOI: 10.1177/15563316231153395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 11/02/2022] [Indexed: 04/18/2023]
Abstract
Background: Patients with inflammatory arthritis are at increased risk of prosthetic joint infections (PJIs), but diagnosis in these patients can be challenging because active inflammatory arthritis produces elevated inflammatory markers that may mimic those seen in PJI. Purpose: In this pilot study, we sought to identify the clinical, microbiologic, and histopathologic features of culture-positive and culture-negative PJI in patients with inflammatory arthritis who underwent total hip arthroplasty (THA) or total knee arthroplasty (TKA). We also sought to obtain preliminary data to support a definitive study of optimal methods for PJI diagnosis in patients with inflammatory arthritis. Methods: We performed a retrospective analysis of TKA and THA patients treated for PJI from 2009 to 2018 at a single tertiary care orthopedic institution. Data were extracted from a longitudinally maintained hospital infection database. We reviewed hematoxylin and eosin slides of osteoarthritis and inflammatory arthritis PJI cases matched 3:1, respectively, by age, sex, and culture status. Clinical characteristics were evaluated using the Fisher exact test, χ2 test, Student t test, and Mann-Whitney U test where appropriate. Results: A total of 807 PJI cases were identified (36 inflammatory arthritis and 771 osteoarthritis cases). Patients with inflammatory arthritis presented younger, had a higher Charlson Comorbidity Index, more frequently used glucocorticoids, were more likely women, and had a higher proportion of culture-negative PJI compared with osteoarthritis patients. Of the 88 inflammatory arthritis cases reviewed for histopathology, a higher proportion of culture-positive than culture-negative PJI cases had >10 polymorphonuclear leucocytes per high-power field and met Musculoskeletal Infection Society criteria but presented with less chronic inflammation. Conclusions: This retrospective prognostic study suggests that culture-negative PJI may be more frequent in patients with inflammatory arthritis than in those with osteoarthritis. Chronic infections, antibiotic use, or misdiagnosis may be contributing factors to unclear PJI diagnoses among culture-negative cases. This preliminary work supports the need for further studies to assess the differences in clinical features between culture-negative and culture-positive PJI in patients with inflammatory arthritis and the ability of biological diagnostic markers to discriminate between them in this population.
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Affiliation(s)
- Peter Sculco
- Department of Medicine, Hospital for
Special Surgery, New York, NY, USA
| | - Milan Kapadia
- Complex Joint Reconstruction Center,
Hospital for Special Surgery, New York, NY, USA
| | | | - Insa Mannstadt
- Department of Medicine, Hospital for
Special Surgery, New York, NY, USA
| | - Andy O. Miller
- Complex Joint Reconstruction Center,
Hospital for Special Surgery, New York, NY, USA
| | - Laura Donlin
- Complex Joint Reconstruction Center,
Hospital for Special Surgery, New York, NY, USA
| | - Michael Henry
- Complex Joint Reconstruction Center,
Hospital for Special Surgery, New York, NY, USA
| | - Linda Russell
- Complex Joint Reconstruction Center,
Hospital for Special Surgery, New York, NY, USA
| | - Mark Figgie
- Complex Joint Reconstruction Center,
Hospital for Special Surgery, New York, NY, USA
| | - Allina Nocon
- Complex Joint Reconstruction Center,
Hospital for Special Surgery, New York, NY, USA
| | - Tania Pannellini
- Department of Medicine, Hospital for
Special Surgery, New York, NY, USA
| | - Susan M. Goodman
- Department of Medicine, Hospital for
Special Surgery, New York, NY, USA
- Susan M. Goodman, MD, Department of
Medicine, Hospital for Special Surgery, 535 East 70th Street, New York, NY
10021, USA.
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21
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Cretu B, Iordache S, Cursaru A, Serban B, Costache M, Cirstoiu C, Spiridonica R. Metagenomic Next-Generation Sequencing for Periprosthetic Joint Infections. Cureus 2023; 15:e38726. [PMID: 37168414 PMCID: PMC10166283 DOI: 10.7759/cureus.38726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2023] [Indexed: 05/13/2023] Open
Abstract
Periprosthetic joint infection (PJI) after arthroplasty is a major complication, which requires significant resources, resulting in high costs for the medical system. In recent years, significant progress has been made in the diagnosis and treatment of periprosthetic infections, the identification of the pathogen being the central element in the establishment of targeted antibiotic therapy. Next-generation sequencing (NGS) or metagenomic NGS (mNGS) represents a promising, fast alternative, with increased specificity and sensitivity compared to identification methods using conventional culture media, thus enabling an increased rate of identification of pathogenic microorganisms and antibiotic resistance genes (ARG). The purpose of this article was to highlight new molecular diagnostic methods for periprosthetic joint infections and their involvement in treatment efficiency. NGS technologies are cutting-edge techniques that may challenge the PJI diagnostic model.
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Affiliation(s)
- Bogdan Cretu
- Orthopedics and Traumatology, University Emergency Hospital, Bucharest, ROU
| | - Sergiu Iordache
- Orthopedics and Traumatology, University Emergency Hospital, Bucharest, ROU
| | - Adrian Cursaru
- Orthopedics and Traumatology, University Emergency Hospital, Bucharest, ROU
| | - Bogdan Serban
- Orthopedics and Traumatology, University Emergency Hospital, Bucharest, ROU
| | - Mihai Costache
- Orthopedics and Traumatology, University Emergency Hospital, Bucharest, ROU
| | - Catalin Cirstoiu
- Orthopedics and Traumatology, University Emergency Hospital, Bucharest, ROU
| | - Razvan Spiridonica
- Orthopedics and Traumatology, University Emergency Hospital, Bucharest, ROU
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22
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Garvin KL, Kildow BJ, Hewlett AL, Hartman CW, Fey PD. The Challenge of Emerging Resistant Gram-Positive Pathogens in Hip and Knee Periprosthetic Joint Infections. J Bone Joint Surg Am 2023:00004623-990000000-00781. [PMID: 37053296 DOI: 10.2106/jbjs.22.00792] [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: 04/15/2023]
Abstract
➤ An increase in resistant bacterial pathogens has occurred over the last 4 decades. ➤ Careful patient selection and improving or correcting risk factors for periprosthetic joint infection (PJI) before elective surgical treatment are strongly recommended. ➤ Appropriate microbiological methods, including those used to detect and grow Cutibacterium acnes, are recommended. ➤ Antimicrobial agents used in the prevention or management of infection should be selected appropriately and the duration of therapy should be carefully considered in order to mitigate the risk of developing bacterial resistance. ➤ Molecular methods including rapid polymerase chain reaction (PCR) diagnostics, 16S sequencing, and/or shotgun and/or targeted whole-genome sequencing are recommended in culture-negative cases of PJI. ➤ Expert consultation with an infectious diseases specialist (if available) is recommended to assist with the appropriate antimicrobial management and monitoring of patients with PJI.
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Affiliation(s)
- Kevin L Garvin
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, Nebraska
| | - Beau J Kildow
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, Nebraska
| | - Angela L Hewlett
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Curtis W Hartman
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, Nebraska
| | - Paul D Fey
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, Nebraska
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23
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Young BC, Dudareva M, Vicentine MP, Hotchen AJ, Ferguson J, McNally M. Microbial Persistence, Replacement and Local Antimicrobial Therapy in Recurrent Bone and Joint Infection. Antibiotics (Basel) 2023; 12:antibiotics12040708. [PMID: 37107070 PMCID: PMC10135193 DOI: 10.3390/antibiotics12040708] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/07/2023] Open
Abstract
We report microbiological results from a cohort of recurrent bone and joint infection to define the contributions of microbial persistence or replacement. We also investigated for any association between local antibiotic treatment and emerging antimicrobial resistance. Microbiological cultures and antibiotic treatments were reviewed for 125 individuals with recurrent infection (prosthetic joint infection, fracture-related infection, and osteomyelitis) at two UK centres between 2007 and 2021. At re-operation, 48/125 (38.4%) individuals had an organism from the same bacterial species as at their initial operation for infection. In 49/125 (39.2%), only new species were isolated in culture. In 28/125 (22.4%), re-operative cultures were negative. The most commonly persistent species were Staphylococcus aureus (46.3%), coagulase-negative Staphylococci (50.0%), and Pseudomonas aeruginosa (50.0%). Gentamicin non-susceptible organisms were common, identified at index procedure in 51/125 (40.8%) and at re-operation in 40/125 (32%). Gentamicin non-susceptibility at re-operation was not associated with previous local aminoglycoside treatment (21/71 (29.8%) vs. 19/54 (35.2%); p = 0.6). Emergence of new aminoglycoside resistance at recurrence was uncommon and did not differ significantly between those with and without local aminoglycoside treatment (3/71 (4.2%) vs. 4/54 (7.4%); p = 0.7). Culture-based diagnostics identified microbial persistence and replacement at similar rates in patients who re-presented with infection. Treatment for orthopaedic infection with local antibiotics was not associated with the emergence of specific antimicrobial resistance.
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Affiliation(s)
- Bernadette C. Young
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford OX3 7LD, UK
- Nuffield Department of Medicine, University of Oxford, Oxford OX3 9DU, UK
| | - Maria Dudareva
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford OX3 7LD, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
| | - Margarete P. Vicentine
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford OX3 7LD, UK
| | - Andrew J. Hotchen
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford OX3 7LD, UK
| | - Jamie Ferguson
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford OX3 7LD, UK
| | - Martin McNally
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford OX3 7LD, UK
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24
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Successful eradication rate following one-stage septic knee and hip exchange in selected pre-operative culture-negative periprosthetic joint infections. INTERNATIONAL ORTHOPAEDICS 2023; 47:659-666. [PMID: 36576518 DOI: 10.1007/s00264-022-05677-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/17/2022] [Indexed: 12/29/2022]
Abstract
PURPOSE The main requirement for performing the one-stage septic exchange is the pre-operative identification of the pathogen and its susceptibility. The purpose of this study is to evaluate the success rate with special focus on reinfection in a cohort of patients who underwent one-stage septic knee or hip revision for pre-operative culture-negative PJI. METHODS We retrospectively analyzed 640 patients treated by one-stage revision for chronic knee or hip PJI between January 1, 2016, and December 31, 2018. Only cases with pre-operative culture-negative PJI, with culture-negative synovial aspirations and one negative open biopsy, were analyzed. We evaluated the septic and aseptic complication and the rate of complication-free survival defined as the time from the date of first operation and the date of complication events. RESULTS A total of 22 patients fulfilled the inclusion and were enrolled. The mean age of the group was 73.2 ± 9.8 years, with a median ASA score of 3 (range 3-4). After mean follow-up of 3.6 ± 2.6 years, 86.4% (19 out of 22) of patients reported no complications. Two patients (9.1%) after one-stage hip required revision arthroplasty due to septic failure, while one patient (4.5%) with one-stage knee had revision for femoral component aseptic loosening. CONCLUSION Our analysis suggests that the absence of pre-operative pathogen detection may not be contraindication to the one-stage revision in selected patients. The one-stage exchange might be considered in patients with pre-operative negative cultures in presence of ASA > 3 and multiple comorbidities that are not able to tolerate multiple surgeries.
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25
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McClure EA, Werth P, Ross B, Gitajn IL. Application of Nucleic Acid-Based Strategies to Detect Infectious Pathogens in Orthopaedic Implant-Related Infection. J Bone Joint Surg Am 2023; 105:556-568. [PMID: 36753571 DOI: 10.2106/jbjs.22.00315] [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: 02/10/2023]
Abstract
➤ Implant-associated infection in orthopaedic surgery remains an enormous and largely unsolved clinical problem with a high rate of persistent or recurrent infection. This may be due, at least in part, to the potential for underdiagnosis by traditional microbial culture or the potential for culture to incompletely identify the microbial species present. ➤ Nucleic acid-based diagnostic techniques, focused on using the diagnostic information contained in DNA or RNA to identify microbial species, have been developing rapidly and have garnered escalating interest for both clinical and research applications. ➤ Commonly applied techniques include end-point polymerase chain reaction (PCR), quantitative PCR, Sanger sequencing, and next-generation sequencing. Understanding the specific strengths and weaknesses of each technique is critical to understanding their utility, applying the correct assessment strategy, and critically understanding and interpreting research. ➤ The best practices for interpreting nucleic acid-based diagnostic techniques include considering positive and negative controls, reads per sample, detection thresholds (for differentiating contaminants from positive results), and the primer set or targeted regions.
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Affiliation(s)
| | - Paul Werth
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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26
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A Permanent Articulating Spacer Versus Two-Stage Exchange for Chronic Periprosthetic Joint Infection: A Propensity Score-Matched Study. J Arthroplasty 2023:S0883-5403(23)00057-8. [PMID: 36720418 DOI: 10.1016/j.arth.2023.01.036] [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: 09/09/2022] [Revised: 01/21/2023] [Accepted: 01/23/2023] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Although 2-stage revision has been proposed as gold standard for periprosthetic joint infection treatment, limited evidence exists for the role of articulating spacers as definitive management. The purpose of this study was to compare clinical outcomes and costs associated with articulating spacers (1.5-stage) and a matched 2-stage cohort. METHODS A retrospective review was performed for patients who had chronic periprosthetic joint infections after total knee arthroplasty defined by Musculoskeletal Infection Society criteria and were matched via propensity score matching using cumulative Musculoskeletal Infection Society scores and a comorbidity index. Patients who maintained an articulating spacer (cemented cobalt-chrome femoral component and all-poly tibia) were included in the 1.5-stage cohort. Patients who underwent a 2-stage reimplantation procedure were included in the 2-stage cohort. Outcomes included visual analog scale pain scores, 90-day emergency department visits, 90-day readmission, unplanned reoperation, reinfection, as well as cost at 1 and 2-year intervals. A total of 116 patients were included for analyses. RESULTS The 90-day pain scores were lower in the 1.5-stage cohort compared to the 2-stage cohort (2.9 versus 4.6, P = .0001). There were no significant differences between readmission and reoperation rates. Infection clearance was equivalent at 79.3% for both groups. Two-stage exchange demonstrated an increased cost difference of $26,346 compared to 1.5-stage through 2 years (P = .0001). Regression analyses found 2 culture-positive results with the same organism decreased the risk for reinfection [odds ratio: 0.2, 95% confidence interval 0.04-0.8, P = .03]. CONCLUSION For high-risk candidates, articulating spacers can preserve knee function, reduce morbidity from second-stage surgery, and lower the costs with similar rates of infection clearance as 2-stage exchange. LEVEL OF EVIDENCE Level III, therapeutic study.
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27
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Hu L, Fu J, Zhou Y, Chai W, Zhang G, Hao L, Chen J. Microbiological profiles and antibiotic resistance of periprosthetic joint infection after hip replacement in patients with fracture or non-fracture: A comparative study. J Back Musculoskelet Rehabil 2023; 36:147-154. [PMID: 36120762 DOI: 10.3233/bmr-210319] [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] [Indexed: 02/04/2023]
Abstract
BACKGROUND Periprosthetic joint infection (PJI) is one of the worst complications following total joint arthroplasty (TJA). Unfortunately, effective prevention strategies to reduce the burden of PJI have not been fully determined in hip replacement patients with fracture and non-fracture. OBJECTIVE This study aimed to analyze and compare the demographic characteristics, microbiological profiles and antibiotic resistance of PJI after hip replacement between patients with fracture and non-fracture. METHODS We retrospectively analyzed the data of 132 patients who treated PJI. There were divided into two groups: non-fracture group (64 patients infected after hip replacement for fracture) and non-fracture group (68 patients infected after hip replacement for non-fracture). Microorganisms were obtained from the synovial fluid and infected necrotic tissue in the joint capsule, medullary cavity, or acetabulum in all patients, and microbiological profiles and antibiotic resistance were evaluated. RESULTS Coagulase-negative staphylococci (CoNS) were the most common pathogenic microorganisms in all patients. Methicillin-resistant Staphylococcus (MRS) accounted for 25% in all pathogenic microbes. Staphylococci showed high drug resistance rates to clindamycin, levofloxacin, and all of the first- and second-generation cephalosporins. MRS isolates in non-fracture group had higher drug resistance rates to clindamycin and levofloxacin than than those in fracture group. Gram-negative bacilli (GNB) showed high drug resistance rates to Aztreonam, gentamicin and all of the third- and fourth-generation cephalosporins. Furthermore, GNB isolates in the non-fracture group showed higher resistance rates to gentamicin and all of the third- and fourth-generation cephalosporins. CONCLUSIONS MRS isolates in the non-fracture group showed higher drug resistance rates to clindamycin and levofloxacin, and GNB isolates in non-fracture group showed higher drug resistance rates to gentamicin and all of the third- and fourth-generation cephalosporins.
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Affiliation(s)
- Lifeng Hu
- Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China.,Department of Orthopedics, The Fifth Central Hospital of Tianjin, Tianjin, China
| | - Jun Fu
- Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China
| | - Yonggang Zhou
- Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China
| | - Wei Chai
- Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China
| | - Guoqiang Zhang
- Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China
| | - Libo Hao
- Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China
| | - Jiying Chen
- Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China
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28
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Meinshausen AK, Färber J, Illiger S, Macor P, Lohmann CH, Bertrand J. C9 immunostaining as a tissue biomarker for periprosthetic joint infection diagnosis. Front Immunol 2023; 14:1112188. [PMID: 36895567 PMCID: PMC9989178 DOI: 10.3389/fimmu.2023.1112188] [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: 11/30/2022] [Accepted: 02/01/2023] [Indexed: 02/23/2023] Open
Abstract
Background Culture-negative periprosthetic joint infections (PJI) are often false diagnosed as aseptic implant failure leading to unnecessary revision surgeries due to repeated infections. A marker to increase the security of e PJI diagnosis is therefore of great importance. The aim of this study was to test C9 immunostaining of periprosthetic tissue as a novel tissue-biomarker for a more reliable identification of PJI, as well as potential cross-reactivity. Method We included 98 patients in this study undergoing septic or aseptic revision surgeries. Standard microbiological diagnosis was performed in all cases for classification of patients. Serum parameters including C-reactive protein (CRP) serum levels and white blood cell (WBC) count were included, and the periprosthetic tissue was immunostained for C9 presence. The amount of C9 tissue staining was evaluated in septic versus aseptic tissue and the amount of C9 staining was correlated with the different pathogens causing the infection. To exclude cross-reactions between C9 immunostaining and other inflammatory joint conditions, we included tissue samples of a separate cohort with rheumatoid arthritis, wear particles and chondrocalcinosis. Results The microbiological diagnosis detected PJI in 58 patients; the remaining 40 patients were classified as aseptic. Serum CRP values were significantly increased in the PJI cohort. Serum WBC was not different between septic and aseptic cases. We found a significant increase in C9 immunostaining in the PJI periprosthetic tissue. To test the predictive value of C9 as biomarker for PJI we performed a ROC analyses. According to the Youden's criteria C9 is a very good biomarker for PJI detection with a sensitivity of 89% and a specificity of 75% and an AUC of 0.84. We did not observe a correlation of C9 staining with the pathogen causing the PJI. However, we observed a cross reactivity with the inflammatory joint disease like rheumatoid arthritis and different metal wear types. In addition, we did not observe a cross reactivity with chondrocalcinosis. Conclusion Our study identifies C9 as a potential tissue-biomarker for the identification of PJI using immunohistological staining of tissue biopsies. The use of C9 staining could help to reduce the number of false negative diagnoses of PJI.
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Affiliation(s)
- Ann-Kathrin Meinshausen
- Department of Orthopaedic Surgery, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Jacqueline Färber
- Institute of Medical Microbiology, Infection Control and Prevention, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Sebastian Illiger
- Department of Orthopaedic Surgery, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Paolo Macor
- Department of Life Sciences, University of Trieste, Trieste, Italy
| | - Christoph H Lohmann
- Department of Orthopaedic Surgery, Otto-von-Guericke University Magdeburg, Magdeburg, Germany.,Health Campus Immunology, Infectiology and Inflammation, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Jessica Bertrand
- Department of Orthopaedic Surgery, Otto-von-Guericke University Magdeburg, Magdeburg, Germany.,Health Campus Immunology, Infectiology and Inflammation, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
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29
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Spichler-Moffarah A, Rubin LE, Bernstein JA, O'Bryan J, McDonald E, Golden M. Prosthetic Joint Infections of the Hip and Knee Among the Elderly: A Retrospective Study. Am J Med 2023; 136:100-107. [PMID: 36063860 DOI: 10.1016/j.amjmed.2022.08.006] [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: 07/14/2022] [Revised: 08/15/2022] [Accepted: 08/16/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND As the population ages and demand for total joint arthroplasty increases, rates of periprosthetic joint infection are expected to increase in the geriatric population. Studies comparing prevalence of risk factors, etiology, management, and mortality of prosthetic joint infection in older patients are lacking. METHODS We compared clinical characteristics, management, and mortality of patients <75 vs ≥75 years of age with first prosthetic joint infection of the hip or knee admitted to a tertiary medical center between September 2017 and December 2019. RESULTS Ninety-eight patients (<75 years of age [n = 63]; ≥75 years of age (n = 35) were studied. Groups were similar in terms of etiology, culture-directed therapy, antibiotic suppression, and length of stay. There was no difference in surgical management, performed in almost 97% of cases in both groups. Arrhythmia and heart failure were more prevalent in those aged ≥75 years. Readmission related to prosthetic joint infection occurred less often in older individuals (P = .005). Deaths within 1 year of diagnosis were rare (n = 4; 4.1%), occurring in older patients and resulting mostly from sepsis. CONCLUSION In our single-center study, patients with first prosthetic joint infection had similar management, regardless of age. We identified cardiac history as one of the host factors for prosthetic joint infection most seen in patients ≥75 years of age. Although deaths were rare, 1-year mortality was higher in patients aged ≥75. Prospective, multicenter studies are needed to explore risk factors and management strategies of prosthetic joint infection among elderly populations.
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Affiliation(s)
- Anne Spichler-Moffarah
- Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn.
| | - Lee E Rubin
- Division of Adult Reconstruction, Department of Orthopedics & Rehabilitation, Yale University School of Medicine, Yale New Haven Health, New Haven, Conn
| | - Jenna A Bernstein
- Division of Adult Reconstruction, Department of Orthopedics & Rehabilitation, Yale University School of Medicine, Yale New Haven Health, New Haven, Conn
| | - Jane O'Bryan
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, Conn; Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, Conn
| | - Erik McDonald
- Division of Adult Reconstruction, Department of Orthopedics & Rehabilitation, Yale University School of Medicine, Yale New Haven Health, New Haven, Conn
| | - Marjorie Golden
- Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
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30
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Comparison of the BioFire Joint Infection Panel to 16S Ribosomal RNA Gene-Based Targeted Metagenomic Sequencing for Testing Synovial Fluid from Patients with Knee Arthroplasty Failure. J Clin Microbiol 2022; 60:e0112622. [PMID: 36409108 PMCID: PMC9769560 DOI: 10.1128/jcm.01126-22] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The diagnosis of periprosthetic joint infection (PJI) is challenging, often requiring multiple clinical specimens and diagnostic techniques, some with prolonged result turnaround times. Here, the diagnostic performance of the Investigational Use Only (IUO) BioFire Joint Infection (JI) Panel was compared to 16S rRNA gene-based targeted metagenomic sequencing (tMGS) applied to synovial fluid for PJI diagnosis. Sixty synovial fluid samples from knee arthroplasty failure archived at -80°C were tested. Infectious Diseases Society of America (IDSA) diagnostic criteria were used to classify PJI. For culture-positive PJI with pathogens targeted by the JI panel, JI panel sensitivity was 91% (21/23; 95% confidence interval [CI], 73 to 98%), and tMGS sensitivity was 96% (23/24; 95% CI, 80 to 99%) (P = 0.56). Overall sensitivities of the JI panel and tMGS for PJI diagnosis were 56% (24/43; 95% CI, 41 to 70%) and 93% (41/44; 95% CI, 82 to 98%), respectively (P < 0.001). JI panel and tMGS overall specificities were 100% (16/16; 95% CI, 81 to 100%) and 94% (15/16; 95% CI, 72 to 99%), respectively. While the clinical sensitivity of the JI panel was excellent for on-panel microorganisms, overall sensitivity for PJI diagnosis was low due to the absence of Staphylococcus epidermidis, a common causative pathogen of PJI, on the panel. A PJI diagnostic algorithm for the use of both molecular tests is proposed.
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31
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Simon S, Frank BJH, Aichmair A, Dominkus M, Mitterer JA, Hartmann SG, Kasparek M, Hofstaetter JG. Alpha-defensin as a diagnostic tool in revision total knee arthroplasties with unexpected positive intraoperative cultures and unexpected culture negative intraoperative cultures. Knee Surg Sports Traumatol Arthrosc 2022; 31:1462-1469. [PMID: 36509937 DOI: 10.1007/s00167-022-07268-w] [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: 05/05/2022] [Accepted: 11/29/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE Unexpected-positive-intraoperative-cultures (UPIC) are common in presumed aseptic revision-total-knee-arthroplasties (rTKA). However, the clinical significance is not entirely clear. In contrast, in some presumably septic rTKA, identification of an underlying pathogen was not possible, so-called unexpected-negative-intraoperative-cultures (UNIC). The purpose of this study was to evaluate the potential use of synovial alpha-defensin (AD) levels in these patients. METHODS Synovial AD levels from 143 rTKAs were evaluated retrospectively from our prospectively maintained institutional periprostetic joint infection (PJI) biobank and database. The 2018-International Consensus Meeting (ICM) criteria was used to define the study groups. Samples from UPICs with a minimum of one positive intraoperative culture (ICM 2- ≥ 6) (n = 20) and UNIC's (ICM ≥ 6) (n = 14) were compared to 34 septic culture-positive samples (ICM ≥ 6) and 75 aseptic culture-negative (ICM 0-1). Moreover, AD-lateral-flow-assay (ADLF) and an enzyme-linked-immunosorbent-assay (ELISA) in detecting the presence of AD in native and centrifuged synovial fluid specimens was performed. Concentration of AD determined by ELISA and ADLF methods, as well as microbiological, and histopathological results, serum and synovial parameters along with demographic factors were analysed. RESULTS AD was positive in 31/34 (91.2%) samples from the septic culture-positive group and in 14/14 (100%) samples in the UNIC group. All UPIC samples showed a negative AD result. Positive AD samples were highly associated with culture positive and histopathological results (p < 0.001). No high-virulent microorganisms (0/20) were present in the UPIC group, compared to infected-group (19/34; 55.9%). High virulent microorganisms showed a positive AD result in 89.5% (17/19) of the cases. Methicillin resistant Staphylococcus epidermis (MRSE) infections had significantly higher AD levels than with methicillin susceptible S. epidermdis (MSSE) (p = 0.003). ELISA and ADLF tests were positive with centrifuged (8/8) and native (8/8) synovial fluid. CONCLUSION AD showed a solid diagnostic performance in infected and non-infected revisions, and it provided an additional value in the diagnosis of UPIC and UNIC associated to rTKAs. Pathogen virulence as well as antibiotic resistance pattern may have an effect on AD levels. Centrifugation of synovial fluid had no influence on ADLF results.
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Affiliation(s)
- Sebastian Simon
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Speisinger Straße 109, Vienna, Austria
- II. Department of Orthopaedic Surgery, Orthopaedic Hospital Vienna-Speising, Speisinger Straße 109, Vienna, Austria
| | - Bernhard J H Frank
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Speisinger Straße 109, Vienna, Austria
| | - Alexander Aichmair
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Speisinger Straße 109, Vienna, Austria
- II. Department of Orthopaedic Surgery, Orthopaedic Hospital Vienna-Speising, Speisinger Straße 109, Vienna, Austria
| | - Martin Dominkus
- II. Department of Orthopaedic Surgery, Orthopaedic Hospital Vienna-Speising, Speisinger Straße 109, Vienna, Austria
- School of Medicine, Sigmund Freud University Vienna, Freudplatz1+3, Vienna, Austria
| | - Jennyfer A Mitterer
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Speisinger Straße 109, Vienna, Austria
| | - Susana Gardete Hartmann
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Speisinger Straße 109, Vienna, Austria
| | - Michael Kasparek
- II. Department of Orthopaedic Surgery, Orthopaedic Hospital Vienna-Speising, Speisinger Straße 109, Vienna, Austria
| | - Jochen G Hofstaetter
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Speisinger Straße 109, Vienna, Austria.
- II. Department of Orthopaedic Surgery, Orthopaedic Hospital Vienna-Speising, Speisinger Straße 109, Vienna, Austria.
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32
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Cobra HADAB, Mozella AP, da Palma IM, Salim R, Leal AC. Cell-free Deoxyribonucleic Acid: A Potential Biomarker of Chronic Periprosthetic Knee Joint Infection. J Arthroplasty 2022; 37:2455-2459. [PMID: 35840076 DOI: 10.1016/j.arth.2022.07.002] [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: 02/18/2022] [Revised: 07/05/2022] [Accepted: 07/06/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The correct diagnosis of a chronic periprosthetic joint infection (PJI) is a major challenge in clinical practice, with the "gold standard" for diagnosis yet to be established. Synovial fluid analysis has been proven to be a useful tool for that purpose. Cell-free DNA (cf-DNA) levels have been shown to be increased in several conditions such as cancer, trauma, and sepsis. Therefore, this study was designed to evaluate the potential of synovial fluid cf-DNA quantification for the diagnosis of chronic periprosthetic infections following total knee arthroplasty. METHODS A prospective study with patients undergoing total knee arthroplasty revision surgery for any indication was performed. PJI diagnosis was defined according to the Second International Consensus Meeting on Musculoskeletal Infection (2018) criteria. The study cohort consisted of 26 patients classified as infected and 40 as noninfected. Synovial fluid cf-DNA direct quantification by fluorescent staining was made. Sensitivity, specificity, and receiver operating characteristic curve were calculated. RESULTS The cf-DNA levels were significantly higher in patients who had PJIs (122.5 ± 57.2 versus 4.6 ± 2.8 ng/μL, P < .0001). With a cutoff of 15 ng/μL, the area under the receiver operating characteristic, sensitivity, and specificity of cf-DNA were 0.978, 96.2%, and 100%, respectively. CONCLUSION The present study has shown that cf-DNA is increased in synovial fluid of patients who have chronic PJIs. It is a promising biomarker for knee PJI diagnosis and further studies are needed to confirm its utility.
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Affiliation(s)
- Hugo A de A B Cobra
- Center for Surgery of Knee, National Institute of Traumatology and Orthopaedics, Rio de Janeiro, Brazil
| | - Alan P Mozella
- Center for Surgery of Knee, National Institute of Traumatology and Orthopaedics, Rio de Janeiro, Brazil
| | - Idemar M da Palma
- Rios D'or Hospital, Rio de Janeiro, Brazil; Montese Medical Center, Rio de Janeiro, Brazil
| | - Rodrigo Salim
- Department of Orthopaedics and Anaesthesiology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Ana C Leal
- Teaching and Research Division, National Institute of Traumatology and Orthopaedics, Rio de Janeiro, Brazil
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"Recommendations for periprosthetic joint infections (PJI) prevention: the European Knee Associates (EKA)-International Committee American Association of Hip and Knee Surgeons (AAHKS)-Arthroplasty Society in Asia (ASIA) survey of members". Knee Surg Sports Traumatol Arthrosc 2022; 30:3932-3943. [PMID: 34518895 DOI: 10.1007/s00167-021-06742-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 09/02/2021] [Indexed: 12/16/2022]
Abstract
PURPOSE Periprosthetic joint infections (PJIs) represent a devastating consequence of total joint arthroplasty. The European Knee Associates (EKA), the American Association of Hip and Knee Surgeons (AAHKS) International Committee, and the Arthroplasty Society in Asia (ASIA) board members were interested in quantifying differences in arthroplasty surgeons' use of various PJI prevention measures to provide clinical recommendations to reduce PJI incidence. METHODS A prospective Microsoft Forms online survey was distributed among EKA, AAHKS International Committee, and ASIA members and their affiliated arthroplasty surgeons. The survey consisted of 20 single and multiple response questions focused on PJI prevention strategies at three perioperative periods: preoperatively, intraoperatively, and postoperatively. RESULTS Three hundred and ninety-four arthroplasty surgeons from 6 different continents completed the survey. Preoperative: (A) PJI Risk Stratification: 40.6% routinely set thresholds (e.g., BMI, HgbA1C) to be met to qualify for surgery, 36.5% only review past medical history; 9.1% use machine learning to personalize PJI risk; (B) BMI limit: 36% no limit; 15.4% BMI < 35; 30.9% BMI < 40; 17.2% BMI < 45; (C) Nutritional status: 55.3% do not screen; among those who screen their patients (44.7%), albumin is the single most used marker (86.3%); (D) Hyperglycemia/Diabetes: 83.3% check this comorbidity; 88.1% use HgbA1C as single best screening test; (E) MRSA nasal colonization: 63.7% do not test; 28.9% test all patients; 7.4% test selectively. Intraoperative: (A) Antibiotic prophylaxis in high-risk patients: 43.4% use single antibiotic for 24 h; 21.3% use double antibiotic for 24 h; 14.2% use single/double antibiotic for 7 days postoperatively; (B) Skin-cleansing: 68.7% at home (45.6% chlorhexidine sponge; 11.9% clippers); (C) Intraoperative skin disinfection: 46.9% single chlorhexidine; 25% double chlorhexidine-povidone-iodine;15.4% single povidone-iodine; (D) Tranexamic acid (TXA) to reduce bleeding/SSI: 96% yes (51% double IV dose, 35.2% single IV dose, 23.6% intra-articular injection); (E) Surgical suction drain: 52% do not use drains; 19.7% use a drain < 24 h; (F) Intra-articular lavage: 64.9% use only saline; 28.1% use dilute povidone-iodine; (G) Antibiotic local delivery to prevent PJI: 82.4% use antibiotic-added cement. Postoperative: (A) Routine monitoring of PJI serologic markers: 42% only in symptomatic patients; 34.2% do not; 20.8% in all patients; (B) Serologic markers to rule in/out PJI: 95.9% CRP; 71% SEDRATE; 60.6% WBC; (C) Synovial fluid test to rule in/out PJI: 79.6% culture/sensitivity; 69.5% WBC count; 31.4% CRP. CONCLUSIONS This survey demonstrated that notable differences still exist in the application of PJI preventive measures across different geographic areas: Optimizing the patient preoperatively and applying multimodal intraoperative strategies represent newer, clinically relevant steps in the effort to reduce the burden of PJI. More uniform guidelines still need to be produced from international scientific societies in order facilitate a more comprehensive approach to this devastating complication. LEVEL OF EVIDENCE IV.
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Paziuk T, Cox RM, Gutman MJ, Rondon AJ, Nicholson T, Belden K, Namdari S. Periprosthetic joint infections of the shoulder: A 10-year retrospective analysis outlining the heterogeneity among these patients. Shoulder Elbow 2022; 14:598-605. [PMID: 36479014 PMCID: PMC9720872 DOI: 10.1177/17585732211019010] [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: 02/24/2021] [Revised: 04/28/2021] [Accepted: 04/29/2021] [Indexed: 11/15/2022]
Abstract
Background Diagnosis and treatment of shoulder periprosthetic joint infection is a difficult problem. The purpose of this study was to utilize the 2018 International Consensus Meeting definition of shoulder periprosthetic joint infection to categorize revision shoulder arthroplasty cases and determine variations in clinical presentation by presumed infection classification. Methods Retrospective review of patients undergoing revision shoulder arthroplasty at a single institution. Likelihood of periprosthetic joint infection was determined based on International Consensus Meeting scoring. All patients classified as definitive or probable periprosthetic joint infection were classified as periprosthetic joint infection. All patients classified as possible or unlikely periprosthetic joint infection were classified as aseptic. The periprosthetic joint infection cohort was subsequently divided into culture-negative, non-virulent microorganism, and virulent microorganism cohorts based on culture results. Results Four hundred and sixty cases of revision shoulder arthroplasty were reviewed. Eighty (17.4%) patients were diagnosed as definite or probable periprosthetic joint infection, of which 29 (36.3%), 39 (48.8%), and 12 (15.0%) were classified as virulent, non-virulent, or culture-negative periprosthetic joint infection, respectively. There were significant differences among periprosthetic joint infection subgroups with regard to preoperative C-reactive protein (p = 0.020), erythrocyte sedimentation rate (p = 0.051), sinus tract presence (p = 0.008), and intraoperative purulence (p < 0.001). The total International Consensus Meeting criteria scores were also significantly different between the periprosthetic joint infection cohorts (p < 0.001). Discussion While the diagnosis of shoulder periprosthetic joint infection has improved with the advent of International Consensus Meeting criteria, there remain distinct differences between periprosthetic joint infection classifications that warrant further investigation to determine the accurate diagnosis and optimal treatment.
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Affiliation(s)
- Taylor Paziuk
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ryan M Cox
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael J Gutman
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexander J Rondon
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Thema Nicholson
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Katherine Belden
- Department of Infectious Disease, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Surena Namdari
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA
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Goh GS, Tarabichi S, Clarkson SJ, Zanna L, Citak M, Parvizi J. Positive Cultures Can Be Safely Ignored in Revision Arthroplasty Patients That Do Not Meet the 2018 International Consensus Meeting Criteria. J Arthroplasty 2022; 37:2257-2261. [PMID: 35569707 DOI: 10.1016/j.arth.2022.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/04/2022] [Accepted: 05/07/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND During aseptic revision total joint arthroplasty (TJA), one or more cultures may occasionally isolate an organism. The hypothesis of this study was that in a portion of patients undergoing revision arthroplasty for aseptic failure, culture may isolate an organism(s) that can be left untreated. METHODS All patients undergoing revision TJA from 2000 to 2017 at two institutions were retrospectively reviewed. Patients were categorized as aseptic if they were appropriately investigated preoperatively and did not meet the 2018 International Consensus Meeting criteria. In the aseptic revision cohort, patients with a single positive culture or multiple cultures positive for different organisms ("organism-positive") and patients who had negative intraoperative cultures ("organism-negative") were compared based on demographics, comorbidities, operative details, subsequent reoperations, and periprosthetic joint infection (PJI). RESULTS In total, 3,234 International Consensus Meeting-negative aseptic revision TJAs were included, of which 215 patients (6.6%) were organism-positive, 196 (91.2%) had a single positive culture, and 19 (8.8%) were positive for 2 or more distinct organisms (ie, polymicrobial). The most prevalent organisms were coagulase-negative Staphylococci (37.5%), Staphylococcus epidermidis (9.6%), and Cutibacterium acnes (8.0%). Demographics and operative details were comparable between the groups. Using multiple regressions there was no association between culture positivity and the rate of reoperation or PJI. CONCLUSION Isolation of organisms by culture in patients undergoing revision for aseptic failure was not uncommon. As long as these patients were appropriately investigated preoperatively and PJI was excluded, these findings suggest that culture results may be ignored without subjecting patients to additional antimicrobial treatment.
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Affiliation(s)
- Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Saad Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Samuel J Clarkson
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Luigi Zanna
- Traumatology and General Orthopedics Department, Careggi University Hospital, Florence, Italy
| | | | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Warren SI, Charville GW, Manasherob R, Amanatullah DF. Immune checkpoint upregulation in periprosthetic joint infection. J Orthop Res 2022; 40:2663-2669. [PMID: 35124851 PMCID: PMC9352818 DOI: 10.1002/jor.25276] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 01/06/2022] [Accepted: 01/16/2022] [Indexed: 02/04/2023]
Abstract
Periprosthetic joint infections (PJI) induce an immunosuppressive cytokine profile through an unknown mechanism. Immune checkpoints, like programmed cell death 1 (PD-1) and its ligand (PD-L1), initiate innate immunosuppressive pathways essential for self-tolerance. Several malignancies and chronic infections co-opt these pathways to derive a survival advantage. This study evaluates PD-1/PD-L1 expression in periprosthetic tissue from patients undergoing revision hip or knee arthroplasty for a PJI versus an aseptic failure. PD-1/PD-L1 in the global tissue sample and the high-power microscopic field of maximum expression was analyzed prospectively using immunohistochemistry. Fifteen patients with a PJI (45%) and 16 patients with an aseptic failure (52%) were included. PD-1 expression was uniformly low. Maximum PD-L1 expression was upregulated in patients with a PJI (25%, interquartile range [IQR]: 5%-75%) versus an aseptic failure, (8%, IQR: 1%-48%, p = 0.039). In the PJI cohort, maximum PD-L1 expression was higher among patients who developed a recurrent PJI (68%, IQR: 53%-86% vs. 15%, IQR: 5%-70%, p = 0.039). Patients with global PD-L1 over 5% trended toward a near 22-fold increase in the odds of reinfection (odds ratio [OR]: 21.9, 95% confidence interval [CI]: 0.9-523.5, p = 0.057) and patients with maximum PD-L1 over 20% trended toward a 15-fold increase in the odds of reinfection (OR: 15.0, 95% CI: 0.6-348.9, p = 0.092). These results support immune checkpoint upregulation as a mechanism of PJI-induced local immune dysfunction. Future studies should confirm PD-L1 as a risk factor for reinfection in larger cohorts.
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Affiliation(s)
- Shay I. Warren
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | | | - Robert Manasherob
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Derek F. Amanatullah
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
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Kullar R, Chisari E, Snyder J, Cooper C, Parvizi J, Sniffen J. Next-Generation Sequencing Supports Targeted Antibiotic Treatment for Culture Negative Orthopedic Infections. Clin Infect Dis 2022; 76:359-364. [PMID: 36074890 PMCID: PMC9839185 DOI: 10.1093/cid/ciac733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/20/2022] [Accepted: 09/01/2022] [Indexed: 01/19/2023] Open
Abstract
The isolation of an infective pathogen can be challenging in some patients with active, clinically apparent infectious diseases. Despite efforts in the microbiology lab to improve the sensitivity of culture in orthopedic implant-associated infections, the clinically relevant information often falls short of expectations. The management of peri-prosthetic joint infections (PJI) provides an excellent example of the use and benefits of newer diagnostic technologies to supplement the often-inadequate yield of traditional culture methods as a substantial percentage of orthopedic infections are culture-negative. Next-generation sequencing (NGS) has the potential to improve upon this yield. Bringing molecular diagnostics into practice can provide critical information about the nature of the infective organisms and allow targeted therapy in these otherwise challenging situations. This review article describes the current state of knowledge related to the use and potential of NGS to diagnose infections, particularly in the setting of PJIs.
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Affiliation(s)
- Ravina Kullar
- Expert Stewardship, Inc. , Newport Beach, California , USA
| | - Emanuele Chisari
- Antimicrobial Stewardship & Infection Prevention, Rothman Orthopaedic Institute, Thomas Jefferson University , Philadelphia, Pennsylvania , USA
| | - James Snyder
- Department of Pathology and Laboratory Medicine, University of Louisville School of Medicine and Hospital , Louisville, Kentucky , USA
| | - Christopher Cooper
- Department of Internal Medicine, Infectious Diseases and Tropical Medicine Section, University of South Florida , Tampa, Florida , USA
| | - Javad Parvizi
- Antimicrobial Stewardship & Infection Prevention, Rothman Orthopaedic Institute, Thomas Jefferson University , Philadelphia, Pennsylvania , USA
| | - Jason Sniffen
- Department of Internal Medicine, Infectious Diseases and Tropical Medicine Section, University of South Florida , Tampa, Florida , USA
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Goswami K, Clarkson S, Phillips CD, Dennis DA, Klatt BA, O'Malley MJ, Smith EL, Gililland JM, Pelt CE, Peters CL, Malkani AL, Palumbo BT, Lyons ST, Bernasek TL, Minter J, Goyal N, McDonald JF, Cross MB, Prieto HA, Lee GC, Hansen EN, Bini SA, Ward DT, Shohat N, Higuera CA, Nam D, Della Valle CJ, Parvizi J. An Enhanced Understanding of Culture-Negative Periprosthetic Joint Infection with Next-Generation Sequencing: A Multicenter Study. J Bone Joint Surg Am 2022; 104:1523-1529. [PMID: 35726882 DOI: 10.2106/jbjs.21.01061] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The challenges of culture-negative periprosthetic joint infection (PJI) have led to the emergence of molecular methods of pathogen identification, including next-generation sequencing (NGS). While its increased sensitivity compared with traditional culture techniques is well documented, it is not fully known which organisms could be expected to be detected with use of NGS. The aim of this study was to describe the NGS profile of culture-negative PJI. METHODS Patients undergoing revision hip or knee arthroplasty from June 2016 to August 2020 at 14 institutions were prospectively recruited. Patients meeting International Consensus Meeting (ICM) criteria for PJI were included in this study. Intraoperative samples were obtained and concurrently sent for both routine culture and NGS. Patients for whom NGS was positive and standard culture was negative were included in our analysis. RESULTS The overall cohort included 301 patients who met the ICM criteria for PJI. Of these patients, 85 (28.2%) were culture-negative. A pathogen could be identified by NGS in 56 (65.9%) of these culture-negative patients. Seventeen species were identified as common based on a study-wide incidence threshold of 5%. NGS revealed a polymicrobial infection in 91.1% of culture-negative PJI cases, with the set of common species contributing to 82.4% of polymicrobial profiles. Escherichia coli, Cutibacterium acnes, Staphylococcus epidermidis, and Staphylococcus aureus ranked highest in terms of incidence and study-wide mean relative abundance and were most frequently the dominant organism when occurring in polymicrobial infections. CONCLUSIONS NGS provides a more comprehensive picture of the microbial profile of infection that is often missed by traditional culture. Examining the profile of PJI in a multicenter cohort using NGS, this study demonstrated that approximately two-thirds of culture-negative PJIs had identifiable opportunistically pathogenic organisms, and furthermore, the majority of infections were polymicrobial. LEVEL OF EVIDENCE Diagnostic Level II . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Karan Goswami
- Rothman Institute at Thomas Jefferson, Philadelphia, Pennsylvania
| | - Samuel Clarkson
- Rothman Institute at Thomas Jefferson, Philadelphia, Pennsylvania
| | - Caleb D Phillips
- Department of Biological Sciences, Texas Tech University, Lubbock, Texas
| | | | - Brian A Klatt
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michael J O'Malley
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Eric L Smith
- New England Baptist Hospital, Chestnut Hill, Massachusetts
| | | | | | | | - Arthur L Malkani
- University of Louisville Adult Reconstruction Program, Louisville, Kentucky
| | - Brian T Palumbo
- University of South Florida Department of Orthopaedic Surgery, Clearwater, Florida
| | - Steven T Lyons
- University of South Florida Department of Orthopaedic Surgery, Clearwater, Florida
| | - Thomas L Bernasek
- University of South Florida Department of Orthopaedic Surgery, Clearwater, Florida
| | | | - Nitin Goyal
- Anderson Orthopaedic Research Institute, Alexandria, Virginia
| | | | | | - Hernan A Prieto
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, Florida
| | - Gwo-Chin Lee
- Penn Presbyterian Medical Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Erik N Hansen
- University of California San Francisco, San Francisco, California
| | - Stefano A Bini
- University of California San Francisco, San Francisco, California
| | - Derek T Ward
- University of California San Francisco, San Francisco, California
| | - Noam Shohat
- Rothman Institute at Thomas Jefferson, Philadelphia, Pennsylvania
| | - Carlos A Higuera
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Dennis Nam
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Javad Parvizi
- Rothman Institute at Thomas Jefferson, Philadelphia, Pennsylvania
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Sigmund IK, Luger M, Windhager R, McNally MA. Diagnosing periprosthetic joint infections : a comparison of infection definitions: EBJIS 2021, ICM 2018, and IDSA 2013. Bone Joint Res 2022; 11:608-618. [PMID: 36047011 PMCID: PMC9533249 DOI: 10.1302/2046-3758.119.bjr-2022-0078.r1] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [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 This study evaluated the definitions developed by the European Bone and Joint Infection Society (EBJIS) 2021, the International Consensus Meeting (ICM) 2018, and the Infectious Diseases Society of America (IDSA) 2013, for the diagnosis of periprosthetic joint infection (PJI). METHODS In this single-centre, retrospective analysis of prospectively collected data, patients with an indicated revision surgery after a total hip or knee arthroplasty were included between 2015 and 2020. A standardized diagnostic workup was performed, identifying the components of the EBJIS, ICM, and IDSA criteria in each patient. RESULTS Of 206 included patients, 101 (49%) were diagnosed with PJI with the EBJIS definition. IDSA and ICM diagnosed 99 (48%) and 86 (42%) as infected, respectively. A total of 84 cases (41%) had an infection based on all three criteria. In 15 cases (n = 15/206; 7%), PJI was present when applying only the IDSA and EBJIS criteria. No infection was detected by one definition alone. Inconclusive diagnoses occurred more frequently with the ICM criteria (n = 30/206; 15%) compared to EBJIS (likely infections: n = 16/206; 8%) (p = 0.029). A better preoperative performance of the EBJIS definition was seen compared with the ICM and IDSA definitions (p < 0.001). CONCLUSION The novel EBJIS definition identified all PJIs diagnosed by any other criteria. Use of the EBJIS definition significantly reduced the number of uncertain diagnoses, allowing easier clinical decision-making.Cite this article: Bone Joint Res 2022;11(9):608-618.
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Affiliation(s)
- Irene K Sigmund
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Markus Luger
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Reinhard Windhager
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Martin A McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
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Garabano G, Gessara AM, Pesciallo CA, Martinez J, del Sel H. Culture-negative Peri-prosthetic Joint Infection after Total Hip Arthroplasty Treatment Protocol and Outcomes in Acute and Chronic Cases. THE ARCHIVES OF BONE AND JOINT SURGERY 2022; 10:806-811. [PMID: 36246023 PMCID: PMC9527426 DOI: 10.22038/abjs.2022.51813.2559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 03/05/2022] [Indexed: 01/24/2023]
Abstract
The treatment of culture-negative periprosthetic joint infections (CN PJI) of the hip represents complex entities. We, as a result of this, report on 12 cases. Irrigation and debridement (I&D) with implant retention were performed in acute cases and two-stage revisions in chronic infections. Combined antibiotic therapy was administered in all cases for 12 weeks. Infection control was achieved in all patients with an infection-free rate of 100% at 7.5 years of average follow-up.
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Affiliation(s)
- Germán Garabano
- Department of Orthopaedic and Traumatology, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Alan Maximiliano Gessara
- Department of Orthopaedic and Traumatology, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Cesar Angel Pesciallo
- Department of Orthopaedic and Traumatology, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Jorge Martinez
- Department of Infectology, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Hernán del Sel
- Department of Orthopaedic and Traumatology, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
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Abdo RCT, Gobbi RG, Leite CBG, Pasoto SG, Leon EP, Lima ALLM, Bonfa E, Pécora JR, Demange MK. Quantitative alpha-defensin testing: Is synovial fluid dilution important? World J Orthop 2022; 13:760-767. [PMID: 36159623 PMCID: PMC9453281 DOI: 10.5312/wjo.v13.i8.760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 02/04/2022] [Accepted: 08/05/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Alpha-defensin has been widely studied for the diagnosis of periprosthetic joint infection (PJI). However, there is a lack of detailed information regarding the proper laboratory technique of the enzyme-linked immunosorbent assay (ELISA) method, such as sample dilution.
AIM To assess the influence of dilution in the synovial fluid during ELISA for the diagnosis of knee PJI; and determine which dilution presents a better performance.
METHODS Forty samples of synovial fluid from arthroplasty knees were included, 17 in the infected group and 23 in the aseptic group, according to Musculoskeletal Infection Society criteria. Initially, five synovial fluid samples from each group were assessed for quantitative analysis of alpha-defensin using ELISA. Different dilution ratios (1:10, 1:100, 1:500, 1:1000 and 1:5000) were tested based on the predetermined cutoff value of 5.2 mg/L. The dilutions that performed better were used to compare the results of all samples.
RESULTS For infected cases, a gradual increase in the dilution of synovial fluid samples led to an equivalent increase in alpha-defensin level. The same was not observed in the aseptic cases. Both 1:1000 and 1:5000 dilutions presented satisfactory results to differentiate infected and aseptic cases. Further analyses were performed using 1:1000 and 1:5000 for all 40 samples. The 1:1000 dilution resulted in a sensitivity of 88.2% (95%CI, 66%-98%) and specificity of 95.7% (95%CI, 79%-99%), whereas the 1:5000 dilution presented a sensitivity of 94.1% (95%CI, 73%-99%) and a specificity of 100% (95%CI, 86%-100%).
CONCLUSION The synovial fluid dilution had an important influence on the alpha-defensin ELISA results. Dilutions of 1:5000 showed the best performance for the diagnosis of knee PJI. The results of this study set the basis for a more reliable and reproducible alpha-defensin ELISA during the investigation of PJI, contributing to the expansion of this technique in different treatment centers worldwide.
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Affiliation(s)
- Rodrigo Calil Teles Abdo
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-010, Brazil
- Orthopaedic Department, HCor - Hospital do Coração, Sao Paulo 04004-030, Brazil
| | - Riccardo Gomes Gobbi
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-010, Brazil
- Orthopaedic Department, HCor - Hospital do Coração, Sao Paulo 04004-030, Brazil
| | - Chilan Bou Ghosson Leite
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-010, Brazil
| | - Sandra Gofinet Pasoto
- Division of Rheumatology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-010, Brazil
| | - Elaine Pires Leon
- Division of Rheumatology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-010, Brazil
| | - Ana Lucia Lei Munhoz Lima
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-010, Brazil
| | - Eloisa Bonfa
- Division of Rheumatology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-010, Brazil
| | - José Ricardo Pécora
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-010, Brazil
| | - Marco Kawamura Demange
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-010, Brazil
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Goh GS, Parvizi J. Diagnosis and Treatment of Culture-Negative Periprosthetic Joint Infection. J Arthroplasty 2022; 37:1488-1493. [PMID: 35101593 DOI: 10.1016/j.arth.2022.01.061] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 01/18/2022] [Indexed: 02/02/2023] Open
Abstract
Identification of the causative organism(s) in periprosthetic joint infection (PJI) is a challenging task. The shortcomings of traditional cultures have been emphasized in recent literature, culminating in a clinical entity known as "culture-negative PJI." Amidst the growing burden of biofilm infections that are inherently difficult to culture, the field of clinical microbiology has seen a paradigm shift from culture-based to molecular-based methods. These novel techniques hold much promise in the demystification of culture-negative PJI and revolutionization of the microbiology laboratory. This article outlines the clinical implications of culture-negative PJI, common causes of this diagnostic conundrum, established strategies to improve culture yield, and newer molecular techniques to detect infectious organisms.
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Affiliation(s)
- Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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Conway JD, Elhessy AH, Galiboglu S, Patel N, Gesheff MG. Efficacy of Infection Eradication in Antibiotic Cement-Coated Intramedullary Nails for Fracture-Related Infections, Nonunions, and Fusions. Antibiotics (Basel) 2022; 11:antibiotics11060709. [PMID: 35740117 PMCID: PMC9219703 DOI: 10.3390/antibiotics11060709] [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: 03/25/2022] [Revised: 05/16/2022] [Accepted: 05/20/2022] [Indexed: 02/01/2023] Open
Abstract
Antibiotic cement-coated intramedullary nails (ACCINs) are increasing in popularity as a viable solution for the treatment of fracture-related infections (FRIs), infected long bone nonunions, and arthrodeses without an external fixator. ACCINs effectively manage to fulfill three of the basic principles for eradicating osteomyelitis: dead space management, antibiotic delivery, and bone stability. We performed a retrospective review of 111 patients who were treated with ACCINs between January 2014 and December 2020. In our series, 87.4% (n = 97) of patients achieved healed and uninfected bone or stable arthrodesis at a mean follow-up of 29.2 months (range, 6–93 months). Additionally, 69.1% (n = 67) of healed patients were resolved after only one procedure, and the remainder (30.9%, n = 30) healed after one or more additional procedures. The mean number of additional procedures was 2.1 (range, 1–6 additional procedures). The overall limb salvage rate was 93.7% (n = 104). The majority of the total cohort were successfully treated in only one surgery. This study suggests that ACCINs are effective in the treatment of FRIs, infected long bone nonunions, and infected ankle and knee arthrodeses.
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Niemann M, Otto E, Braun KF, Graef F, Ahmad SS, Hardt S, Stöckle U, Trampuz A, Meller S. Microbiological Advantages of Open Incisional Biopsies for the Diagnosis of Suspected Periprosthetic Joint Infections. J Clin Med 2022; 11:jcm11102730. [PMID: 35628857 PMCID: PMC9143629 DOI: 10.3390/jcm11102730] [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: 03/23/2022] [Revised: 04/27/2022] [Accepted: 05/03/2022] [Indexed: 02/01/2023] Open
Abstract
Background: Periprosthetic joint infection (PJI) represents a serious complication following total hip (THA) and knee arthroplasty (TKA). When preoperative synovial fluid cultures remain inconclusive, open incisional joint biopsy (OIB) can support causative microorganism identification. Objective: This study investigates the potential benefit of OIB in THA and TKA patients with suspected PJI and ambigious diagnostic results following synovial fluid aspiration. Methods: We retrospectively assessed all patients treated from 2016 to 2020 with suspected PJI. Comparing the microbiology of OIB and the following revision surgery, we calculated sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and the number needed to treat (NNT). Results: We examined the diagnostic validity of OIB in 38 patients (20 female) with a median age of 66.5 years. In THA patients (n = 10), sensitivity was 75%, specificity was 66.67%, PPV was 60%, NPV was 80%, and NNT was 2.5. In TKA patients (n = 28), sensitivity was 62.5%, specificity was 95.24%, PPV was 83.33%, NPV was 86.96%, and NNT was 1.42. Conclusions: Our results indicate that OIB represents an adequate diagnostic tool when previously assessed microbiological results remain inconclusive. Particularly in TKA patients, OIB showed an exceptionally high specificity, PPV, and NPV, whereas the predictive validity of the diagnosis of PJI in THA patients remained low.
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Affiliation(s)
- Marcel Niemann
- Center for Musculoskeletal Surgery, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany; (E.O.); (K.F.B.); (F.G.); (S.S.A.); (S.H.); (U.S.); (A.T.); (S.M.)
- Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Berlin Institute of Health at Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany
- Correspondence: ; Tel.: +49-30-450-652-256; Fax: +49-30-450-552-901
| | - Ellen Otto
- Center for Musculoskeletal Surgery, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany; (E.O.); (K.F.B.); (F.G.); (S.S.A.); (S.H.); (U.S.); (A.T.); (S.M.)
- Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Berlin Institute of Health at Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Karl F. Braun
- Center for Musculoskeletal Surgery, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany; (E.O.); (K.F.B.); (F.G.); (S.S.A.); (S.H.); (U.S.); (A.T.); (S.M.)
- Department of Trauma Surgery, University Hospital Rechts der Isar, Technical University of Munich, 80333 Munich, Germany
| | - Frank Graef
- Center for Musculoskeletal Surgery, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany; (E.O.); (K.F.B.); (F.G.); (S.S.A.); (S.H.); (U.S.); (A.T.); (S.M.)
| | - Sufian S. Ahmad
- Center for Musculoskeletal Surgery, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany; (E.O.); (K.F.B.); (F.G.); (S.S.A.); (S.H.); (U.S.); (A.T.); (S.M.)
- Department of Orthopedic Surgery, Hannover Medical School, 30625 Hannover, Germany
| | - Sebastian Hardt
- Center for Musculoskeletal Surgery, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany; (E.O.); (K.F.B.); (F.G.); (S.S.A.); (S.H.); (U.S.); (A.T.); (S.M.)
| | - Ulrich Stöckle
- Center for Musculoskeletal Surgery, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany; (E.O.); (K.F.B.); (F.G.); (S.S.A.); (S.H.); (U.S.); (A.T.); (S.M.)
| | - Andrej Trampuz
- Center for Musculoskeletal Surgery, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany; (E.O.); (K.F.B.); (F.G.); (S.S.A.); (S.H.); (U.S.); (A.T.); (S.M.)
| | - Sebastian Meller
- Center for Musculoskeletal Surgery, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany; (E.O.); (K.F.B.); (F.G.); (S.S.A.); (S.H.); (U.S.); (A.T.); (S.M.)
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Wallander K, Vondracek M, Giske CG. Evaluation of multi-sample 16S ribosomal DNA sequencing for the diagnosis of postoperative bone and joint infections during antimicrobial treatment. BMC Res Notes 2022; 15:113. [PMID: 35317829 PMCID: PMC8939158 DOI: 10.1186/s13104-022-05992-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/07/2022] [Indexed: 11/28/2022] Open
Abstract
Objectives Clinicians worldwide struggle to identify the bacterial aetiology of bone and joint infections. Failure to unequivocally identify the pathogen is linked to poor clinical outcomes. We explored the added value of analysing multiple samples per patient with 16S ribosomal DNA (16S rDNA) sequencing in diagnosing postoperative bone and joint infections. All patients had received antimicrobials prior to sampling, and false-negative cultures could be suspected. Bone biopsies obtained from patients with postoperative bone and joint infections for cultures were also subjected to 16S rDNA sequencing. Results In 5/28 infectious episodes, sequencing identified the causative organism of the infection when cultures failed. In 8/28 episodes, the methods led to different results, potentially leading to different antimicrobial choices. The analysis of multiple samples per patient helped rule out potential contaminating pathogens. We conclude that 16S rDNA sequencing has diagnostic value for patients receiving antibiotic treatment. We regard the method as a complement to culturing when the cultures are negative. Multiple samples per patient should be analysed to determine the clinical significance of positive findings.
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Affiliation(s)
- Katja Wallander
- Department of Infectious Diseases and Venhälsan, Södersjukhuset, Stockholm, Sweden. .,Division of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
| | - Martin Vondracek
- Department of Clinical Microbiology, Karolinska University Hospital Stockholm, Stockholm, Sweden.,Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Christian G Giske
- Department of Clinical Microbiology, Karolinska University Hospital Stockholm, Stockholm, Sweden.,Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
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46
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Atkin B, Dupley L, Chakravorty P, Zafar K, Boden R. Approach to patients with a potential prosthetic joint infection. BMJ 2022; 376:e069502. [PMID: 35314426 DOI: 10.1136/bmj-2021-069502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- B Atkin
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - L Dupley
- Lancashire Teaching Hospitals NHS Foundation Trust, UK
| | - P Chakravorty
- Lancashire Teaching Hospitals NHS Foundation Trust, UK
| | - K Zafar
- New Collegiate Medical Centre, Cheetham Hill and Crumpsall Primary Care Network, Manchester, UK
| | - R Boden
- Lancashire Teaching Hospitals NHS Foundation Trust, UK
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47
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Berneking L, Haas M, Frielinghaus L, Berinson B, Lütgehetmann M, Christner M, Aepfelbacher M, Gerlach U, Seide K, Both A, Rohde H. Evaluation of a syndromic panel polymerase chain reaction (spPCR) assay for the diagnosis of device-associated bone and joint infections (BJI). Int J Infect Dis 2022; 116:283-288. [PMID: 35031396 DOI: 10.1016/j.ijid.2022.01.013] [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: 08/11/2021] [Revised: 01/05/2022] [Accepted: 01/05/2022] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE Pathogen detection is crucial for diagnosis and targeted therapy in implant-associated bone and joint infections (BJI). Culture-based microbiology regularly fails to identify causative pathogens. This study evaluated the diagnostic accuracy and clinical usefulness of a syndromic panel polymerase chain reaction (spPCR) assay targeting common BJI pathogens in tissue specimens from patients with implant-associated BJI. METHODS Results obtained by spPCR assay and a 16S rDNA PCR were compared with results obtained from a standard of care (SOC) culture-based diagnostics, serving as a gold standard. In total, 126 specimens obtained from 73 patients were analyzed. RESULTS The spPCR assay correctly identified 33/40 culture-positive samples (82.5 %) and was positive in 9/86 (10.5 %) culture-negative samples, resulting in an overall sensitivity of 84.6 % (95% confidence interval [CI] 68.79-93.59%) and specificity of 89.35% (95% CI 80.6-94.81%). The spPCR was more sensitive compared with the 16S rDNA PCR (37.5%). The spPCR identified pathogens in 7/51 (13.7%) SOC-negative patients. Re-evaluation of spPCR results in clinical context suggested their clinical significance. CONCLUSION An spPCR assay targeting common pathogens causing implant-associated BJI may help to identify causative agents in culture-negative cases. As false-negative results are possible, spPCR assays appear as an add-on approach for pathogen detection in implant-associated BJI.
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Affiliation(s)
- Laura Berneking
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Michaela Haas
- Septische Unfallchirurgie und Orthopädie, BG Klinikum Hamburg, Hamburg, Germany
| | - Lisa Frielinghaus
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Benjamin Berinson
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Marc Lütgehetmann
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Christner
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Aepfelbacher
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Ulf Gerlach
- Septische Unfallchirurgie und Orthopädie, BG Klinikum Hamburg, Hamburg, Germany
| | - Klaus Seide
- Septische Unfallchirurgie und Orthopädie, BG Klinikum Hamburg, Hamburg, Germany
| | - Anna Both
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Holger Rohde
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.
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Vaz K, Taylor A, Kendrick B, Alvand A. A guide to debridement, antibiotics, and implant retention. ANNALS OF JOINT 2022; 7:5. [PMID: 38529146 PMCID: PMC10929291 DOI: 10.21037/aoj-20-89] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 09/01/2020] [Indexed: 03/27/2024]
Abstract
Debridement, antibiotics, and implant retention (DAIR) is an alternative management strategy for the treatment of periprosthetic joint infection (PJI). While infection eradication rates are lower with DAIR, the benefits including decreased morbidity, improved functional outcomes, and decreased cost may justify the risks when considering this form of treatment compared to traditional one or two stage exchange arthroplasty. Implant longevity in the setting of a successful DAIR is similar to matched patients who have not experienced a PJI. An experienced arthroplasty surgeon well versed in extensile exposure should perform the DAIR. This procedure should not be viewed as a simple "washout." While PJI may be considered a surgical urgency, DAIR can be performed on a planned list if it allows for appropriate staffing and implants for the procedure. Arthroscopic irrigation may be performed for a patient in extremis but it should not be viewed as a definitive procedure to address PJI. Keys to a successful DAIR include accurate tissue sampling to determine the infective organism, meticulous, radical debridement, and exchange of modular components if possible. A multidisciplinary team (MDT) including an infectious disease specialist should be involved prior to surgery in order to guide appropriate antimicrobial therapy throughout the patient's course of treatment. In the article below we present our indications, considerations, and technique for performing a DAIR for PJI for hip and knee arthroplasty.
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Affiliation(s)
- Kenneth Vaz
- Nuffield Orthopaedic Centre and University of Oxford, Botnar Research Centre, Oxford, UK
| | - Adrian Taylor
- Nuffield Orthopaedic Centre and University of Oxford, Botnar Research Centre, Oxford, UK
| | - Ben Kendrick
- Nuffield Orthopaedic Centre and University of Oxford, Botnar Research Centre, Oxford, UK
| | - Abtin Alvand
- Nuffield Orthopaedic Centre and University of Oxford, Botnar Research Centre, Oxford, UK
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Day CW, Costi K, Pannach S, Atkins GJ, Hofstaetter JG, Callary SA, Nelson R, Howie DW, Solomon LB. Long-Term Outcomes of Staged Revision Surgery for Chronic Periprosthetic Joint Infection of Total Hip Arthroplasty. J Clin Med 2021; 11:jcm11010122. [PMID: 35011863 PMCID: PMC8745559 DOI: 10.3390/jcm11010122] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 12/20/2021] [Accepted: 12/22/2021] [Indexed: 11/16/2022] Open
Abstract
Periprosthetic joint infection (PJI) is a serious complication of total hip arthroplasty. Staged revision surgery is considered effective in eradicating PJI. We aimed to determine the rate of infection resolution after each stage of staged revision surgery (first stage, repeat first stage, second stage, excision arthroplasty, and reimplantation) and to assess functional outcomes and the mortality rate at ten years in a consecutive series of 30 chronic PJI of total hip arthroplasties. Infection resolution was defined as no clinical nor laboratory evidence of infection at 24 months after the last surgery and after a minimum of 12 months following cessation of antimicrobial treatment. Four patients died within 24 months of their final surgery. Nineteen patients, 73% (worst-case analysis (wca) 63%), were infection free after 1 surgery; 22 patients, 85% (wca 73%), were infection free after 2 surgeries; and 26 patients, 100% (wca 87%), were infection free after three and four surgeries. The median Harris Hip Score was 41 prior to first revision surgery and improved to 74 at twelve months and 76 at ten years after the final surgery. Thirteen patients died at a mean of 64 months from first revision, giving a mortality rate of 43% at ten years, which is approximately 25% higher than that of an age-matched general population. The results show that with repeated aggressive surgical treatment, most PJIs of the hip are curable. Ten years after successful treatment of PJI, functional outcomes and pain are improved and maintained compared to before initial surgery, but this must be balanced against the high 10-year mortality. Level of evidence: cohort studies.
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Affiliation(s)
- Christopher W. Day
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA 5000, Australia; (C.W.D.); (S.P.); (S.A.C.); (D.W.H.); (L.B.S.)
| | - Kerry Costi
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA 5000, Australia; (C.W.D.); (S.P.); (S.A.C.); (D.W.H.); (L.B.S.)
- Centre for Orthopaedic and Trauma Research, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA 5005, Australia;
- Correspondence: ; Tel.: +618-707-42112
| | - Susan Pannach
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA 5000, Australia; (C.W.D.); (S.P.); (S.A.C.); (D.W.H.); (L.B.S.)
| | - Gerald J. Atkins
- Centre for Orthopaedic and Trauma Research, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA 5005, Australia;
| | - Jochen G. Hofstaetter
- Ludwig Boltzmann Institute of Osteology, Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1st Medical Department Hanusch Hospital, 1140 Vienna, Austria;
- Michael Ogon Laboratory, Orthopaedic Hospital Vienna-Speising, 1130 Vienna, Austria
| | - Stuart A. Callary
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA 5000, Australia; (C.W.D.); (S.P.); (S.A.C.); (D.W.H.); (L.B.S.)
- Centre for Orthopaedic and Trauma Research, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA 5005, Australia;
| | - Renjy Nelson
- Department of Infectious Diseases, Royal Adelaide Hospital, Adelaide, SA 5000, Australia;
| | - Donald W. Howie
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA 5000, Australia; (C.W.D.); (S.P.); (S.A.C.); (D.W.H.); (L.B.S.)
- Centre for Orthopaedic and Trauma Research, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA 5005, Australia;
| | - Lucian B. Solomon
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA 5000, Australia; (C.W.D.); (S.P.); (S.A.C.); (D.W.H.); (L.B.S.)
- Centre for Orthopaedic and Trauma Research, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA 5005, Australia;
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Tang Y, Zhao D, Wang S, Yi Q, Xia Y, Geng B. Diagnostic Value of Next-Generation Sequencing in Periprosthetic Joint Infection: A Systematic Review. Orthop Surg 2021; 14:190-198. [PMID: 34935279 PMCID: PMC8867422 DOI: 10.1111/os.13191] [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: 03/08/2021] [Revised: 11/11/2021] [Accepted: 11/19/2021] [Indexed: 01/03/2023] Open
Abstract
Next‐generation sequencing (NGS) has developed rapidly in the last decade and is emerging as a promising diagnostic tool for periprosthetic joint infection (PJI). However, its diagnostic value for PJI is still uncertain. This systematic review aimed to explore the diagnostic value of NGS for PJI and verify its accuracy for culture‐negative PJI patients. We conducted this systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) guidelines. Medline, Embase, and Cochrane Library were searched to identify diagnostic technique studies evaluating the accuracy of NGS in the diagnosis of PJI. The diagnostic sensitivity, specificity, and positive and negative predictive values were estimated for each article. The detection rate of NGS for culture‐negative PJI patients or PJI patients with antibiotic administration history was also calculated. Of the 87 identified citations, nine studies met the inclusion criteria. The diagnostic sensitivities and specificities of NGS ranged from 63% to 96% and 73% to 100%, respectively. The positive and negative predictive values ranged from 71% to 100% and 74% to 95%, respectively. The detection rate of NGS for culture‐negative PJI patients in six studies was higher than 50% (range from 82% to 100%), while in three studies it was lower than 50% (range from 9% to 31%). Also, the detection rate of NGS for PJIs with antibiotic administration history ranged from 74.05% to 92.31%. In conclusion, this systematic review suggests that NGS may have the potential to be a new tool for the diagnosis of PJI and should be considered to be added to the portfolio of diagnostic procedures. Furthermore, NGS showed a favorable diagnostic accuracy for culture‐negative PJI patients or PJI patients with antibiotic administration history. However, due to the small sample sizes of studies and substantial heterogeneity among the included studies, more research is needed to confirm or disprove these findings.
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Affiliation(s)
- Yuchen Tang
- Department of Orthopaedics, Lanzhou University Second Hospital, Orthopaedic Key Laboratory of Gansu Province, Orthopaedic Clinical Research Center of Gansu Province, Lanzhou, China
| | - Dacheng Zhao
- Department of Orthopaedics, Lanzhou University Second Hospital, Orthopaedic Key Laboratory of Gansu Province, Orthopaedic Clinical Research Center of Gansu Province, Lanzhou, China
| | - Shenghong Wang
- Department of Orthopaedics, Lanzhou University Second Hospital, Orthopaedic Key Laboratory of Gansu Province, Orthopaedic Clinical Research Center of Gansu Province, Lanzhou, China
| | - Qiong Yi
- Department of Orthopaedics, Lanzhou University Second Hospital, Orthopaedic Key Laboratory of Gansu Province, Orthopaedic Clinical Research Center of Gansu Province, Lanzhou, China
| | - Yayi Xia
- Department of Orthopaedics, Lanzhou University Second Hospital, Orthopaedic Key Laboratory of Gansu Province, Orthopaedic Clinical Research Center of Gansu Province, Lanzhou, China
| | - Bin Geng
- Department of Orthopaedics, Lanzhou University Second Hospital, Orthopaedic Key Laboratory of Gansu Province, Orthopaedic Clinical Research Center of Gansu Province, Lanzhou, China
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