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Naoum S, Koutserimpas C, Pantekidis I, Giovanoulis V, Veizi E, Piagkou M, Ioannou P, Samonis G, Domouchtsidou A, Tsantes AG, Papadopoulos DV. Antimicrobial Regimens in Cement Spacers for Periprosthetic Joint Infections: A Critical Review. Antibiotics (Basel) 2024; 13:772. [PMID: 39200072 PMCID: PMC11351621 DOI: 10.3390/antibiotics13080772] [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: 07/17/2024] [Revised: 08/11/2024] [Accepted: 08/13/2024] [Indexed: 09/01/2024] Open
Abstract
Antibiotic-loaded cement spacers (ALCSs) are essential for treating periprosthetic joint infections (PJIs) by providing mechanical support and local antibiotic delivery. The purpose of this review is to comprehensively examine the various types of spacers utilised in the management of periprosthetic joint infections (PJIs), including both static and articulating variants and to analyse the fundamental principles underlying spacer use, their clinical benefits, the selection and administration of antimicrobial agents, appropriate dosages, and potential adverse effects. Articulating spacers, which allow joint mobility, often yield better outcomes than static ones. Spacer pharmacokinetics are vital for maintaining therapeutic antibiotic levels, influenced by cement porosity, mixing techniques, and the contact area. Antibiotic choice depends on heat stability, solubility, and impact on cement's mechanical properties. Mechanical properties are crucial, as spacers must withstand physical stresses, with antibiotics potentially affecting these properties. Complications, such as tissue damage and systemic toxicity, are discussed, along with mitigation strategies. Future advancements include surface modifications and novel carriers to enhance biofilm management and infection control.
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Affiliation(s)
- Symeon Naoum
- Department of Trauma and Orthopaedics, Royal Berkshire Hospital, Reading RG1 5AN, UK;
| | - Christos Koutserimpas
- Orthopaedic Surgery and Sports Medicine Department, Croix-Rousse Hospital, University Hospital, 69317 Lyon, France
- Department of Anatomy, School of Medicine, Faculty of Health Sciences, National and Kapodistrian University of Athens, 75 Mikras Asias Str., Goudi, 11527 Athens, Greece;
| | - Ioannis Pantekidis
- Department of Trauma and Orthopaedics, Guy’s and St. Thomas’ NHS Foundation Trust, London SE1 7EH, UK
| | - Vasileios Giovanoulis
- Department of Orthopaedic Surgery, Hôpital Henri Mondor, AP-HP, Université Paris Est Créteil (UPEC), 94010 Creteil, France;
| | - Enejd Veizi
- Department of Orthopedics and Traumatology, Yıldırım Beyazıt University, Ankara City Hospital, Ankara 2367, Turkey;
| | - Maria Piagkou
- Department of Anatomy, School of Medicine, Faculty of Health Sciences, National and Kapodistrian University of Athens, 75 Mikras Asias Str., Goudi, 11527 Athens, Greece;
| | - Petros Ioannou
- School of Medicine, University of Crete, 71003 Heraklion, Greece (G.S.)
| | - George Samonis
- School of Medicine, University of Crete, 71003 Heraklion, Greece (G.S.)
- First Department of Medical Oncology, Metropolitan Hospital of Neon Faliron, 18547 Athens, Greece
| | - Aglaia Domouchtsidou
- Microbiology Department, “Saint Savvas” Oncology Hospital, 11522 Athens, Greece; (A.D.); (A.G.T.)
| | - Andreas G. Tsantes
- Microbiology Department, “Saint Savvas” Oncology Hospital, 11522 Athens, Greece; (A.D.); (A.G.T.)
- Laboratory of Hematology and Blood Bank Unit, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Dimitrios V. Papadopoulos
- 2nd Academic Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 14233 Athens, Greece;
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朱 家, 孙 家, 马 博, 张 驰, 曹 逊, 郑 善, 陈 志, 张 超, 沈 计, 夏 天. [Study on effectiveness of antibiotics guided by metagenomic next-generation sequencing to control infection after total knee arthroplasty]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2024; 38:995-1000. [PMID: 39175323 PMCID: PMC11335594 DOI: 10.7507/1002-1892.202404044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 07/07/2024] [Accepted: 07/15/2024] [Indexed: 08/24/2024]
Abstract
Objective To explore the clinical value of metagenomic next-generation sequencing (mNGS) in diagnosis and treatment of periprosthetic joint infection (PJI) after total knee arthroplasty (TKA). Methods Between April 2020 and March 2023, 10 patients with PJI after TKA were admitted. There were 3 males and 7 females with an average age of 69.9 years (range, 44-83 years). Infection occurred after 8-35 months of TKA (mean, 19.5 months). The duration of infection ranged from 16 to 128 days (mean, 37 days). The preoperative erythrocyte sedimentation rate (ESR) was 15-85 mm/1 h (mean, 50.2 mm/1 h). The C reactive protein (CRP) was 4.4-410.0 mg/L (mean, 192.8 mg/L). The white blood cell counting was (3.4-23.8)×10 9/L (mean, 12.3×10 9/L). The absolute value of neutrophils was (1.1-22.5)×10 9/L (mean, 9.2×10 9/L). After admission, the joint fluid was extracted for bacterial culture method and mNGS test, and sensitive antibiotics were chosen according to the results of the test, and the infection was controlled in combination with surgery. Results Seven cases (70%) were detected as positive by bacterial culture method, and 7 types of pathogenic bacteria were detected; the most common pathogenic bacterium was Streptococcus lactis arrestans. Ten cases (100%) were detected as positive by mNGS test, and 11 types of pathogenic bacteria were detected; the most common pathogenic bacterium was Propionibacterium acnes. The difference in the positive rate between the two methods was significant ( P=0.211). Three of the 7 patients who were positive for both the bacterial culture method and the mNGS test had the same results for the type of pathogenic bacteria, with a compliance rate of 42.86% (3/7). The testing time (from sample delivery to results) was (4.95±2.14) days for bacterial culture method and (1.60±0.52) days for mNGS test, and the difference was significant ( t=4.810, P<0.001). The corresponding sensitive antibiotic treatment was chosen according to the results of bacterial culture method and mNGS test. At 3 days after the one-stage operation, the CRP was 6.8-48.2 mg/L (mean, 23.6 mg/L); the ESR was 17-53 mm/1 h (mean, 35.5 mm/1 h); the white blood cell counting was (4.5-8.1)×10 9/L (mean, 6.1×10 9/L); the absolute value of neutrophils was (2.3-5.7)×10 9/L (mean, 4.1×10 9/L). All patients were followed up 12-39 months (mean, 23.5 months). One case had recurrence of infection at 6 months after operation, and the remaining 9 cases showed no signs of infection, with an infection control rate of 90%. Conclusion Compared with bacterial culture method, mNGS test can more rapidly and accurately detect pathogenic bacteria for PJI after TKA, which is important for guiding antibiotics combined with surgical treatment of PJI.
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Affiliation(s)
- 家庆 朱
- 南京中医药大学附属医院骨伤科(南京 210029)Department of Orthopaedics, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing Jiangsu, 210029, P. R. China
| | - 家豪 孙
- 南京中医药大学附属医院骨伤科(南京 210029)Department of Orthopaedics, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing Jiangsu, 210029, P. R. China
| | - 博闻 马
- 南京中医药大学附属医院骨伤科(南京 210029)Department of Orthopaedics, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing Jiangsu, 210029, P. R. China
| | - 驰宇 张
- 南京中医药大学附属医院骨伤科(南京 210029)Department of Orthopaedics, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing Jiangsu, 210029, P. R. China
| | - 逊 曹
- 南京中医药大学附属医院骨伤科(南京 210029)Department of Orthopaedics, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing Jiangsu, 210029, P. R. China
| | - 善斌 郑
- 南京中医药大学附属医院骨伤科(南京 210029)Department of Orthopaedics, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing Jiangsu, 210029, P. R. China
| | - 志远 陈
- 南京中医药大学附属医院骨伤科(南京 210029)Department of Orthopaedics, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing Jiangsu, 210029, P. R. China
| | - 超 张
- 南京中医药大学附属医院骨伤科(南京 210029)Department of Orthopaedics, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing Jiangsu, 210029, P. R. China
| | - 计荣 沈
- 南京中医药大学附属医院骨伤科(南京 210029)Department of Orthopaedics, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing Jiangsu, 210029, P. R. China
| | - 天卫 夏
- 南京中医药大学附属医院骨伤科(南京 210029)Department of Orthopaedics, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing Jiangsu, 210029, P. R. China
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Starnes V, Duggan J, Hollingshead C. Fungal Prosthetic Joint Infection: A Case Series and Review of the Literature. Infect Dis Ther 2024; 13:1051-1065. [PMID: 38613628 PMCID: PMC11098995 DOI: 10.1007/s40121-024-00964-9] [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: 01/23/2024] [Accepted: 03/18/2024] [Indexed: 04/15/2024] Open
Abstract
INTRODUCTION Fungal prosthetic joint infections comprise less than 1% of prosthetic joint infections. Thus, little is known regarding optimal management. This study aims to characterize the microbiology, surgical and medical management, and outcomes for these complex infections. The objectives of this study were to assess the impact of surgical approach, antifungal treatment, fungal species, and time to onset of infection from initial surgery on patient outcomes. METHODS A retrospective record review over 12 years was performed in two health systems that included patients with a deep culture positive for a fungal isolate and the presence of a prosthetic joint. A literature review was performed using the same inclusion criteria. A total of 289 cases were identified and analyzed. RESULTS Candida was the most common isolate, and a two-stage revision was the most commonly employed surgical modality. The type of surgical intervention had a statistically significant relationship with outcome (P = 0.022). CONCLUSIONS Two-stage revision with extended antifungal therapy is preferred in these infections due to higher rates of positive outcomes.
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Affiliation(s)
- Victoria Starnes
- The University of Toledo College of Medicine and Life Sciences, Toledo, USA
| | - Joan Duggan
- Division of Infectious Diseases, The University of Toledo College of Medicine and Life Sciences, Toledo, USA
| | - Caitlyn Hollingshead
- Division of Infectious Diseases, The University of Toledo College of Medicine and Life Sciences, Toledo, USA.
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Krampitz B, Steiner J, Trampuz A, Kühn KD. Voriconazole Admixed with PMMA-Impact on Mechanical Properties and Efficacy. Antibiotics (Basel) 2023; 12:antibiotics12050848. [PMID: 37237751 DOI: 10.3390/antibiotics12050848] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/25/2023] [Accepted: 04/27/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND There are currently no recommendations to direct the optimal diagnosis and treatment of fungal osteoarticular infections, including prosthetic joint infections and osteomyelitis. Active agents (fluconazole; amphotericin B) are regularly applied per os or intravenously. Other drugs such as voriconazole are used less frequently, especially locally. Voriconazole is less toxic and has promising results. Local antifungal medication during primary surgical treatment has been investigated by implanting an impregnated PMMA cement spacer using intra-articular powder or by daily intra-articular lavage. The admixed dosages are rarely based on characteristic values and microbiological and mechanical data. The purpose of this in vitro study is to investigate the mechanical stability and efficacy of antifungal-admixed PMMA with admixed voriconazole at low and high concentrations. METHODS Mechanical properties (ISO 5833 and DIN 53435) as well as efficacy with inhibition zone tests with two Candida spp. were investigated. We tested three separate cement bodies at each measuring time (n = 3) Results: Mixing high dosages of voriconazole causes white specks on inhomogeneous cement surfaces. ISO compression, ISO bending, and DIN impact were significantly reduced, and ISO bending modulus increased. There was a high efficacy against C. albicans with low and high voriconazole concentrations. Against C. glabrata, a high concentration of voriconazole was significantly more efficient than a dose at a low concentration. CONCLUSIONS Mixing voriconazole powder with PMMA (Polymethylmethacrylate) powder homogeneously is not easy because of the high amount of dry voriconazole in the powder formulation. Adding voriconazole (a powder for infusion solutions) has a high impact on its mechanical properties. Efficacy is already good at low concentrations.
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Affiliation(s)
- Barbara Krampitz
- Medical Training and Science, Heraeus Medical GmhH, Hamburger Allee 50, 60486 Frankfurt, Germany
| | - Julia Steiner
- University Hospital for Orthopaedics and Traumatology, Medical University of Graz, 8036 Graz, Austria
| | - Andrej Trampuz
- Infectious Diseases, Center for Musculoskeletal Surgery, Charité, Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Klaus-Dieter Kühn
- University Hospital for Orthopaedics and Traumatology, Medical University of Graz, 8036 Graz, Austria
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Prosthetic Knee Joint Infection Due to Candida lusitaniae: A Diagnostic and Therapeutic Odyssey: A Case Study. Diagnostics (Basel) 2022; 12:diagnostics12112640. [DOI: 10.3390/diagnostics12112640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/17/2022] [Accepted: 10/27/2022] [Indexed: 11/16/2022] Open
Abstract
Prosthetic joint infections (PJIs) caused by fungi, although relatively rare, represent a major surgery-related complication. An extremely rare fungal PJI, following revised total knee replacement (TKR) caused by Candida lusitaniae, is reported, and a meticulous review of similar cases is provided. A 74-year-old female, who underwent primary total knee arthroplasty 10 years ago and a revision surgery three weeks ago, presented with signs and symptoms of PJI. C. lusitaniae was eventually isolated from the periprosthetic tissue using the MALDI-TOF VitekMS–bioMérieux technique. Multiple strategies for managing this fungal PJI were performed, and finally, the patient was treated successfully with an intramedullary arthrodesis system and proper antifungal treatment, including fluconazole. A multidisciplinary approach is essential for the diagnosis and treatment of such severe infections. In persistent cases and in cases where revision surgery is extremely difficult to perform, arthrodesis seems to be an effective solution for the elimination of the infection. The efficacy of the therapeutic management of fungal PJIs remains unclear. Therefore, more research should be reported, focusing on proper treatment so that the optimal strategy in treating these severe infections may be established.
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