Prosthetic joint infection of the hip and knee due to Mycobacterium species: A systematic review

Application of a metatranscriptomics technology, CSI-Dx, for the detection of pathogens associated with prosthetic joint infections

Preoperative identification of causal organism(s) is crucial for effective prosthetic joint infection treatment. Herein, we explore the clinical application of a novel metatranscriptomic (MT) workflow, CSI-Dx, to detect pathogens associated with prosthetic joint infection. MT provides insight into transcriptionally active microbes, overcoming limitations of culture-based and available molecular methods. This study included 340 human synovial fluid specimens subjected to CSI-Dx and traditional culture-based methods. Exploratory analyses were conducted to determine sensitivity and specificity of CSI-Dx for detecting clinically-relevant taxa. Our findings provide insights into the active microbial community composition of synovial fluid from arthroplasty patients and demonstrate the potential clinical utility of CSI-Dx for aiding prosthetic joint infection diagnosis. This approach offers potential for improved sensitivity and acceptable specificity compared to synovial fluid culture, enabling detection of culturable and non-culturable microorganisms. Furthermore, CSI-Dx provides valuable information on antimicrobial resistance gene expression. While further optimization is needed, integrating metatranscriptomic technologies like CSI-Dx into routine clinical practice can revolutionize prosthetic joint infection diagnosis by offering a comprehensive and active snapshot of associated pathogens.

Implant-associated Mycobacterium tuberculosis infection (IMTI) in long-term, well-fixed implants

Background

Orthopedic device infections caused by Mycobacterium tuberculosis, including Periprosthetic joint infection (PJI), are rare and peculiar due to its poor adherence to implant surface and weak ability of biofilm formation. We present successful treatment of 2 cases of implant associated Mycobacterium tuberculosis infection (IMTI) by meticulous surgical debridement and long-term anti-tubercular chemotherapy with retention of implant.

Case descriptions

Case 1 : A case of Culture-Negative PJI, 4 years after left total hip replacement (THR) caused by M. tuberculosis. The patient presented with acute onset (<7 days) low grade fever and development of discharging sinus from the site of left surgical scar mark. Case 2: A patient with Kuntscher nailing done for open fracture right femur 22 years ago presented to clinic with complaints of discharging sinus (<7 days) from the surgical scar mark on right side. Both patients had negative cultures on presentation and underwent meticulous debridement with implant retention. Intra-operative samples were positive for M. tuberculosis on CB-NAAT and histopathology. They underwent successful treatment with 18 months of Anti Tubercular Treatment (ATT) without any relapse at 2 year-follow-up.

Conclusion

Atypical, late onset discharging sinus with negative cultures should raise suspicion of IMTI. Intra-operative deep tissue samples should be analyzed for CB-NAAT for M. tuberculosis and histopathological analysis in all these cases. Meticulous debridement with 18 months chemotherapy poses viable option for successful treatment of IMTI, allowing retention of prosthesis.

Clinical Characteristics and Outcomes of Extrapulmonary Nontuberculous Mycobacterial Infections in a Tertiary-Care Hospital: A Retrospective Study

Background/Objectives: The incidence of nontuberculous mycobacterial (NTM) infections has increased globally; however, the clinical manifestations and optimal treatment strategies for extrapulmonary NTM infections remain poorly defined. This study assessed the clinical manifestations and treatment outcomes of extrapulmonary NTM infections. Methods: Data from adult patients with suspected extrapulmonary NTM infections at a tertiary-care hospital from 2009-2022 were categorized into NTM disease and isolation groups. Diagnosis of NTM disease relied on stringent criteria, whereas isolation required NTM isolation without meeting the criteria for infection. Results: Among 75 patients evaluated, 32 (42%) were diagnosed with NTM disease and 43 (57%) with NTM isolation. History of immunosuppressant use within the past 3 months (p = 0.070) and injection (p = 0.001) were more frequent in the disease group. The median interval from symptom onset to evaluation was 106.6 and 20 days in the disease and isolation groups, respectively. The prevalence of positive NTM polymerase chain reaction results (36.4%, p = 0.003) and acid-fast bacillus staining (39.1%, p < 0.001) was significantly higher in the disease group than in the isolation group. Mycobacterium intracellulare (21.9%), M. abscessus (15.6%), M. chelonae (9.4%), and M. fortuitum complex (9.4%) were the most frequently identified species. Of the 27 patients in the disease group who received treatment, 13 improved, four experienced treatment failure, seven were lost to follow-up, and three died during treatment, with one death directly attributable to NTM disease. Conclusions: NTM disease exhibits a spectrum of clinical manifestations. Accurate diagnosis is crucial for initiating effective treatment.

Management of M. abscessus subsp. abscessus early-onset prosthetic joint infection: Case report and literature review

Nontuberculous mycobacteria are a rare but still emerging cause of difficult-to-treat prosthetic joint infection. To our knowledge only 17 cases of M. abscessus complex prosthetic joint infection are reported in literature, of which only 1 is by M. abscessus subps. abscessus. No guidelines are available for this clinical scenario. We describe a 68-years-old female patient with an early-onset M. abscessus subsp. abscessus prosthetic joint infection, successfully treated with a tailored medical-surgical strategy, and present an overview of cases currently available in the literature to assist physicians in the management of these uncommon infections.

Mycobacterium flavescens Infection - An Unusual Case of Prosthetic Joint Infection

INTRODUCTION

The onset of prosthetic joint infections (PJIs) is characterized by early onset defined as within 90 days of the procedure, delayed onset defined as within 3 to 12 months, and late onset defined as over 12 months. In only a scant number of case reports, Mycobacterium flavescens associated infections are typically found in sputum cultures and associated with various forms of penetrating joint traumas, particularly post-surgical interventions. Due to its rarity in presentation among cases of PJIs, we have presented a case of PJI caused by Mycobacterium flavescens.

CASE PRESENTATION

We have, herein, reported a case of a 70-year-old male presenting with stabbing left knee pain over the past several months along with accompanying erythema and swelling with the presence of purulent discharge. Outpatient cultures have shown the growth of Mycobacterium flavescent; subsequently, the patient underwent a 2-stage revision arthroplasty and was treated with a three-drug regimen and implant 5 months later. Although being an atypical cause of PJIs, we emphasize the importance of considering NTM as a differential for immunocompromised patients, especially those with prior surgical intervention.

DISCUSSION

Mycobacterium spp. related PJIs manifest clinical features similar to other bacteriacausing PJIs, such as warm, indurated edema at the surgical site resulting in wound dehiscence and joint effusion. Diagnosis of Mycobacterium spp. related PJIs includes history and physical examination findings, serum inflammatory markers, synovial fluid analysis, and culture. Concurrently with surgical interventions, utilization of antimicrobial agents provides additional control in Mycobacterium- related PJI. Mycobacterium flavescens should be included among other NTMs as a possible cause of PJIs.

A case report on Mycobacterium houstonense infection after total hip arthroplasty

BACKGROUND

Mycobacterium houstonense is a category of rapidly growing mycobacteria that is gram-positive, acid-fast, polycrystalline, and non-spore-forming. There have been few reports of human infection caused by Mycobacterium houstonense worldwide.

CASE PRESENTATION

We present a case of chronic periprosthetic joint infection caused by Mycobacterium houstonense in an elderly female patient. The patient developed signs of infection after undergoing total hip arthroplasty. Despite receiving antibiotic treatment and revision surgery, the signs of infection recurred repeatedly. Multiple bacterial cultures during the treatment period were negative. Later, we identified the pathogenic bacteria Mycobacterium houstonense through mNGS testing, isolated the bacteria from the ultrasonically centrifuged fluid of the prosthesis and obtained drug sensitivity results. Finally, we performed a revision surgery and treated the patient with moxifloxacin and clindamycin. After treatment, the patient did not show signs of infection recurrence during 24 months of follow-up.

CONCLUSION

Through a relevant literature search, we believe that Mycobacterium houstonense may show higher sensitivity to amikacin and quinolone antibiotics. Additionally, clarifying occult infection sources through methods such as gene testing will improve the diagnosis and treatment of periprosthetic joint infection.

Periprosthetic Joint Infection Diagnosis: A Narrative Review

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.

Mycobacterium avium complex prosthetic joint infection: A systematic review of the literature and pooled analysis

BACKGROUND

Mycobacterium avium complex (MAC) prosthetic joint infection (PJI) has been rarely reported.

METHODS

This study aimed to investigate the epidemiology and outcomes of MAC PJI. A systematic review of the literature regarding the MAC infection following total joint arthroplasty including hip and knee joint was performed. Multiple databases were searched for published English-written articles up to May 2023. Studies that reported cases of PJI by MAC were reviewed.

RESULTS

A total of 17 patients were identified and analyzed from 11 published studies. All patients presented with joint symptom of pain or swelling prior to the diagnosis and MAC was confirmed by culture. The most of the patients (16/17 patients, 94.1%) were noted to have underlying medical condition(s) that might have affected immunity. Treatment consisted of anti-MAC medication therapy only in two patients and anti-MAC medication therapy plus surgery in 15 patients. Among the patients who underwent surgery, 14 patients (82.3%) had removal of the prosthesis including seven patients who had two-stage surgery to have reimplantation of the prosthesis. No relapse of MAC infection was reported despite of one case of relapse of infection caused by different pyogenic bacteria. The rate of overall mortality was 29.4%, however, identified attributable mortality due to MAC infection was low (5.9%).

CONCLUSION

PJI by MAC is a rare disease. However, MAC needs to be considered in the differential diagnosis in immunocompromised patients presenting with symptoms of PJI. Two-stage exchange arthroplasty may result in successful treatment outcomes without higher risks of relapse of infection if undertaken in association with appropriate active anti-MAC antibiotic therapy.

Mycobacterium biofilms

The genus Mycobacterium includes some of the deadliest pathogens of History (Mycobacterium tuberculosis, Mycobacterium leprae), but most of the species within the genus are environmental microorganisms. Because some of these nontuberculous mycobacteria (NTM) species can be human pathogens, the study of these mycobacterial biofilms has increased during the last decades, and the interest in this issue increased as well as the growing number of patients with diseases caused by NTM. Different molecular mechanisms have been described, being especially well known the importance of glycopeptidolipids. Moreover, the knowledge of the extracellular matrix has shown important differences with other microorganisms, especially because of the presence of lipidic molecules as a key component of this structure. The clinical importance of mycobacterial biofilms has been described for many chronic diseases, especially lung diseases and implant-related ones, both in vitro and in vivo, and even in patients. Moreover, the biofilm-producing capacity has been proven also in M. tuberculosis, while its importance is not well understood. Biofilm studies have also shown the increasing resistance of mycobacteria in sessile form, and the importance of this resistance in the management of the patients is beyond doubt, being surgery necessary in some cases to cure the patients. Diagnosis of mycobacterial diseases is still based on culture-based techniques designed for the detection of M. tuberculosis. Molecular biology-based methods are also broadly used but again designed for tuberculosis diagnosis. Antimicrobial susceptibility testing is also well developed for tuberculosis, but only some species of NTM have standardized techniques for this purpose. New tools or approaches are necessary to treat these patients, whose importance is increasing, as the number of potential hosts is also increasing throughout the world.