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Kuthan R, Zaremba-Wróblewski GL, Ott F, Soltaninia D. Septic Obturation of a Knee Endoprosthesis Caused by Aspergillus clavatus. Pathogens 2023; 12:1270. [PMID: 37887786 PMCID: PMC10610210 DOI: 10.3390/pathogens12101270] [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: 09/13/2023] [Revised: 10/11/2023] [Accepted: 10/18/2023] [Indexed: 10/28/2023] Open
Abstract
Aspergillus clavatus is a rare opportunistic fungal pathogen that can be isolated from various environmental sources, including soil and animal feces. Although infrequent, infections caused by A. clavatus can be severe in immunocompromised patients. Here, we present a case of a prosthetic joint infection (PJI) in a 74-year-old female patient caused by A. clavatus. The patient presented with left knee pain, and septic loosening of the left knee endoprosthesis was diagnosed. She underwent surgical revision with the implantation of an antibiotic spacer and microbiologic testing. The results came back positive for both Staphylococcus lugdunensis and A. clavatus (which is found in only a fraction of a percent of PJIs). She was treated with oral antimicrobials for 3 months postoperatively. This case report vividly illustrates a clinical scenario that underscores the significance of rigorous microbiologic testing procedures, accurate pathogen identification, unwavering vigilance in testing protocols, and a cautious approach that avoids succumbing to the seductive simplicity of Occam's razor.
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Affiliation(s)
- Robert Kuthan
- Chair and Department of Medical Microbiology, Medical University of Warsaw, 02-004 Warsaw, Poland;
- Student Scientific Club Microbiology Applied to Clinics and Real Life for Students (MACR-S) Affiliated to Chair and Department of Medical Microbiology, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Gabriel Lawrence Zaremba-Wróblewski
- Chair and Department of Medical Microbiology, Medical University of Warsaw, 02-004 Warsaw, Poland;
- Student Scientific Club Microbiology Applied to Clinics and Real Life for Students (MACR-S) Affiliated to Chair and Department of Medical Microbiology, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Flynn Ott
- Student Scientific Club Microbiology Applied to Clinics and Real Life for Students (MACR-S) Affiliated to Chair and Department of Medical Microbiology, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Dorsa Soltaninia
- Student Scientific Club Microbiology Applied to Clinics and Real Life for Students (MACR-S) Affiliated to Chair and Department of Medical Microbiology, Medical University of Warsaw, 02-091 Warsaw, Poland
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Burke ZDC, Hart CM, Kelley BV, Mamouei Z, Blumstein GW, Hamad C, Hori K, Cevallos N, Villalpando C, Truong N, Turkmani A, Ralston M, Kavanaugh A, Tenorio E, Kauvar LM, Li A, Prunet N, Stavrakis AI, Bernthal NM. Monoclonal Antibody Disrupts Biofilm Structure and Restores Antibiotic Susceptibility in an Orthopedic Implant Infection Model. Antibiotics (Basel) 2023; 12:1490. [PMID: 37887191 PMCID: PMC10604051 DOI: 10.3390/antibiotics12101490] [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: 08/29/2023] [Revised: 09/20/2023] [Accepted: 09/26/2023] [Indexed: 10/28/2023] Open
Abstract
Bacterial biofilms on orthopedic implants are resistant to the host immune response and to traditional systemic antibiotics. Novel therapies are needed to improve patient outcomes. TRL1068 is a human monoclonal antibody (mAb) against a biofilm anchoring protein. For assessment of this agent in an orthopedic implant infection model, efficacy was measured by reduction in bacterial burden of Staphylococcus aureus, the most common pathogen for prosthetic joint infections (PJI). Systemic treatment with the biofilm disrupting mAb TRL1068 in conjunction with vancomycin eradicated S. aureus from steel pins implanted in the spine for 26 of 27 mice, significantly more than for vancomycin alone. The mechanism of action was elucidated by two microscopy studies. First, TRL1068 was localized to biofilm using a fluorescent antibody tag. Second, a qualitative effect on biofilm structure was observed using scanning electron microscopy (SEM) to examine steel pins that had been treated in vivo. SEM images of implants retrieved from control mice showed abundant three-dimensional biofilms, whereas those from mice treated with TRL1068 did not. Clinical Significance: TRL1068 binds at high affinity to S. aureus biofilms, thereby disrupting the three-dimensional structure and significantly reducing implant CFUs in a well-characterized orthopedic model for which prior tested agents have shown only partial efficacy. TRL1068 represents a promising systemic treatment for orthopedic implant infection.
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Affiliation(s)
- Zachary D. C. Burke
- Department of Orthopedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; (C.M.H.); (B.V.K.)
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Christopher M. Hart
- Department of Orthopedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; (C.M.H.); (B.V.K.)
| | - Benjamin V. Kelley
- Department of Orthopedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; (C.M.H.); (B.V.K.)
| | - Zeinab Mamouei
- Orthopedic Hospital Research Center, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA (K.H.)
| | - Gideon W. Blumstein
- Department of Orthopedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; (C.M.H.); (B.V.K.)
| | - Christopher Hamad
- Orthopedic Hospital Research Center, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA (K.H.)
| | - Kellyn Hori
- Orthopedic Hospital Research Center, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA (K.H.)
| | - Nicolas Cevallos
- Orthopedic Hospital Research Center, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA (K.H.)
| | - Christina Villalpando
- Orthopedic Hospital Research Center, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA (K.H.)
| | - Nicole Truong
- Orthopedic Hospital Research Center, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA (K.H.)
| | - Amr Turkmani
- Orthopedic Hospital Research Center, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA (K.H.)
| | - Micah Ralston
- Orthopedic Hospital Research Center, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA (K.H.)
| | - Aaron Kavanaugh
- Orthopedic Hospital Research Center, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA (K.H.)
| | - Edgar Tenorio
- Trellis Bioscience, Inc., Redwood City, CA 94063, USA
| | | | - Alan Li
- Department of Molecular, Cell and Developmental Biology, University of California, Los Angeles, CA 90095, USA
| | - Nathanael Prunet
- Department of Molecular, Cell and Developmental Biology, University of California, Los Angeles, CA 90095, USA
| | - Alexandra I. Stavrakis
- Department of Orthopedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; (C.M.H.); (B.V.K.)
| | - Nicholas M. Bernthal
- Department of Orthopedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; (C.M.H.); (B.V.K.)
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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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Piperacillin Steady State Concentrations in Target Tissues Relevant for PJI Treatment—A Randomized Porcine Microdialysis Study Comparing Continuous Infusion with Intermittent Short-Term Infusion. Antibiotics (Basel) 2023; 12:antibiotics12030577. [PMID: 36978444 PMCID: PMC10044349 DOI: 10.3390/antibiotics12030577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/12/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023] Open
Abstract
(1) Introduction: Piperacillin is a common antibiotic choice in the treatment of periprosthetic joint infections (PJI) caused by Pseudomonas aeruginosa. The aim of this study was to assess and compare the time with free piperacillin concentration above the minimum inhibitory concentration (fT > MIC) at steady state in target tissues relevant for PJI treatment following continuous and intermittent short-term infusion. (2) Methods: 16 pigs were randomized to receive either continuous or intermittent short-term infusion of piperacillin. Steady state piperacillin concentrations were assessed using microdialysis in tibial cortical bone, tibial cancellous bone, synovial fluid of the knee joint, and subcutaneous tissue. MIC-targets of 4, 8, 16, and 64 mg/L were applied. Plasma samples were obtained as reference. (3) Results: Continuous infusion resulted in longer fT > MIC for MIC targets of 4 mg/L and 8 mg/L compared to intermittent short-term infusion in all compartments with the exception of tibial cortical bone. For the MIC-target of 16 mg/L, continuous infusion resulted in a longer fT > MIC in all compartments except for the bone compartments. No differences between groups were seen when applying a MIC-target of 64 mg/L. (4) Conclusions: An aggressive dosing strategy may be necessary to obtain sufficient piperacillin concentrations in all bone compartments, particularly if more aggressive targets are applied. Based on the present study, continuous infusion should be considered in the treatment of PJI.
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Microbiological Trends and Antibiotic Susceptibility Patterns in Patients with Periprosthetic Joint Infection of the Hip or Knee over 6 Years. Antibiotics (Basel) 2022; 11:antibiotics11091244. [PMID: 36140023 PMCID: PMC9495258 DOI: 10.3390/antibiotics11091244] [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: 08/13/2022] [Revised: 09/05/2022] [Accepted: 09/09/2022] [Indexed: 12/02/2022] Open
Abstract
We sought to analyze trends of the causative pathogens and their antibiotic susceptibility patterns in patients with periprosthetic joint infections (PJI) of the hip and knee to get better insights and improve treatment. Retrospective evaluation of all consecutive patients with microbiological detection of a causative pathogen at a tertiary endoprothetic referral center between January 2016 and December 2021 in Germany was performed. Overall, 612 different microorganisms could be detected in 493 patients (hip: n = 293; knee: n = 200). Evaluation did not show a change in the relative abundance of pathogens detected, with coagulase-negative staphylococci (n = 275; 44.9%) found frequently, followed by S. aureus (n = 86; 14.1%), Enterococcus species (n = 57; 9.3%), Streptococcus species (n = 48; 7.8%), and Gram-negative bacteria (n = 80; 13.1%). Evaluation of the antibiotic susceptibilities showed increasing rates of oxacillin-resistant coagulase-negative staphylococci (60.4%; 46.8−76.7%) and piperacillin-tazobactam-resistant Gram-negative bacteria (26.5%; 0−57.1%), although statistically not significant. Resistance of Gram-positive bacteria to vancomycin (<1%) and Gram-negative microorganisms to meropenem (1.25%) remained an exception. In summary, coagulase-negative staphylococci, as the most frequent pathogen, displayed a continuously high rate of oxacillin resistance. For the highest antimicrobial coverage in the case of an empiric therapy/unknown pathogen, vancomycin might be chosen. Level of evidence: IV.
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