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Madariaga MC, O'Malley NA, Groff H, Alben M, Papalia A, Fogel J, Thompson J, Apazidis A. Does hydrogen peroxide help mitigate the incidence of Cutibacterium acnes in cervical spine surgeries? NORTH AMERICAN SPINE SOCIETY JOURNAL 2024; 19:100514. [PMID: 39175928 PMCID: PMC11339044 DOI: 10.1016/j.xnsj.2024.100514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 06/06/2024] [Accepted: 06/25/2024] [Indexed: 08/24/2024]
Abstract
Background Surgical site infection (SSI) is a common yet serious complication of cervical spine surgery. While initially thought to be clinically insignificant, Cutibacterium acnes (C. acnes) is an important cause of infection. The purpose of this study was to investigate the ability of a hydrogen peroxide (H2O2) application during standard presurgical skin preparation to reduce the burden of C. acnes in patients undergoing cervical spine surgery. Methods This was a retrospective review of prospectively collected data. Subjects were randomly assigned to either standard surgical preparation plus H2O2 (experimental) or without H2O2 (control). Prescrub, postscrub, and dermal cultures were obtained to assess the C. acnes burden after cultures on an aerobic and anaerobic growth medium were held for 21 days. Multivariate analysis was conducted to determine factors associated with presence of C. acnes. Outcome measures included the results of intraoperative cultures and the development of a SSI within 90 days postoperatively. Results Patients (n=86) undergoing elective 2- or 3-level fusion via anterior approach were included. Prior to application of the antiseptic solution, 65% (28/43) of the experimental cohort and 77% (33/43) of the control cohort had positive C. acnes cultures (p=.34). Following application of antiseptic solution, there were no differences in positive C. acnes culture rates between the experimental and control cohorts in the epidermal (30% vs. 28%, p=1.00) or dermal (40% vs. 42%, p=1.00) cultures. No differences in the rates of C. acnes eradication from preantiseptic to postantiseptic application occurred for epidermal (p=1.00) or dermal (p=1.00) skin layers. None of the factors were associated with positive C. acnes epidermal cultures on multivariable logistic regression analysis (p>.05). Conclusions While there is potential for H2O2 to reduce the positive culture rate of C. acnes in cervical spine patients, no difference was seen when compared to standard surgical skin preparation.
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Affiliation(s)
| | - Nicholas A. O'Malley
- Department of Orthopaedic Surgery, Nassau University Medical Center, East Meadow, NY 11554
| | - Hannah Groff
- Department of Orthopaedic Surgery, Nassau University Medical Center, East Meadow, NY 11554
| | - Matthew Alben
- State University at Buffalo, Department of Orthopedic Surgery, Buffalo, NY
| | - Aidan Papalia
- Geisnger Health, Department of Orthopedic Surgery, Danville, PA
| | - Joshua Fogel
- Department of Biostatistics, Nassau University Medical Center, East Meadow, NY 11554
| | - Jeffrey Thompson
- Department of Orthopaedic Surgery, Nassau University Medical Center, East Meadow, NY 11554
| | - Alexios Apazidis
- Department of Orthopaedic Surgery, Nassau University Medical Center, East Meadow, NY 11554
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Baroudi M, Daher M, Parks RD, Gregoryczyk JG, Balmaceno-Criss M, McDonald CL, Diebo BG, Daniels AH. Cutibacterium acnes in spine surgery: pathophysiology, diagnosis, and treatment. Spine J 2024; 24:1545-1552. [PMID: 38679079 DOI: 10.1016/j.spinee.2024.04.018] [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: 01/27/2024] [Revised: 04/23/2024] [Accepted: 04/23/2024] [Indexed: 05/01/2024]
Abstract
Cutibacterium acnes (C. acnes) previously named Propionibacterium acnes (P. acnes) has been increasingly recognized by spine surgeons as a cause of indolent postsurgical spinal infection. Patients infected with C. acnes may present with pseudarthrosis or nonspecific back pain. Currently, microbiological tissue cultures remain the gold standard in diagnosing C. acnes infection. Ongoing research into using genetic sequencing as a diagnostic method shows promising results and may be another future way of diagnosis. Optimized prophylaxis involves the use of targeted antibiotics, longer duration of antibiotic prophylaxis, antibacterial-coated spinal implants, and evidence-based sterile surgical techniques all of which decrease contamination. Antibiotics and implant replacement remain the mainstay of treatment, with longer durations of antibiotics proving to be more efficacious. Local guidelines must consider the surge of antimicrobial resistance worldwide when treating C. acnes.
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Affiliation(s)
- Makeen Baroudi
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, 1 Kettle Point Ave, Providence, RI 02914, USA
| | - Mohammad Daher
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, 1 Kettle Point Ave, Providence, RI 02914, USA
| | - Russell D Parks
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, 1 Kettle Point Ave, Providence, RI 02914, USA
| | - Jerzy George Gregoryczyk
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, 1 Kettle Point Ave, Providence, RI 02914, USA
| | - Mariah Balmaceno-Criss
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, 1 Kettle Point Ave, Providence, RI 02914, USA
| | - Christopher L McDonald
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, 1 Kettle Point Ave, Providence, RI 02914, USA
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, 1 Kettle Point Ave, Providence, RI 02914, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, 1 Kettle Point Ave, Providence, RI 02914, USA.
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Duan Y, Feng D, Zou K, Yang F, Chen R, Huang Y. The Relationship Between Modic Changes and Endplate Sclerosis in Patients with Lumbar Degenerative Disease: A Systematic Review and Network Meta-Analysis. World Neurosurg 2024; 186:7-16. [PMID: 38479643 DOI: 10.1016/j.wneu.2024.03.017] [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: 02/11/2024] [Accepted: 03/05/2024] [Indexed: 04/08/2024]
Abstract
OBJECTIVE To explore the relationship between modic changes (MCs) and endplate sclerosis in patients with lumbar degenerative disease. METHODS This network meta-analysis was performed on the basis of Preffered Reporting Items for Systematic Reviews and Meta-Analysis 2020 statement. This study was registered at the International Prospective Register of Systematic Reviews (CRD42024497370). We performed a systematic search of the PubMed, Web of Science, Embase, China national knowledge infrastructure, China Science and Technology Journal Database, and Wanfang databases from inception to December 22, 2023. STATA13.0 and RevMan 5.3 were applied to perform the meta-analysis. RESULTS Seven studies with a total of 1510 endplates were divided into 6 groups according to the type of MCs. The endplate sclerosis rate in the single-type group was significantly lower than that in the mixed-type group. The endplate sclerosis rate in the type I MC (MC1) was significantly lower than that in the type II MC (MC2). The endplate sclerosis rate in the MC2 was significantly lower than that in the type III MC (MC3). The endplate sclerosis rate in the MC1/2 was significantly lower than that in the MC2/3. No significant difference was detected between MC1/2 and MC1/3 or between MC2/3 and MC1/3. For decreasing the endplate sclerosis rate, the order of the different types of MCs was MC1>MC2>MC1/2>MC2/3≈MC1/3>MC3. CONCLUSIONS Endplate sclerosis occurs in all kinds of MCs. With increasing grade of MCs, the incidence of endplate sclerosis gradually increased. The endplate sclerosis rate in mixed-type MCs was significantly greater than that in MC2 and significantly lower than that in MC3. The endplate sclerosis rate in the mixed-type, including MC3 (MC1/3 and MC2/3), was significantly greater than that in the MC1/2.
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Affiliation(s)
- Yuchen Duan
- Department of Orthopedics, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Dagang Feng
- Department of Orthopedics, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Kai Zou
- Department of Orthopedics, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Fei Yang
- Department of Orthopedics, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Rigao Chen
- Department of Orthopedics, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Yong Huang
- Department of Orthopedics, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China.
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El Yaagoubi Y, Lioret E, Thomas C, Loret JE, Simonneau A, Michaud-Robert AV, Philippe L, Ogielska M, Prunier-Aesch C. Value of 18 F-FDG PET/CT to Identify Occult Infection in Presumed Aseptic Pseudarthrosis after Spinal Fusion: Correlation with Intraoperative Cultures. World J Nucl Med 2024; 23:17-24. [PMID: 38595836 PMCID: PMC11001461 DOI: 10.1055/s-0044-1778711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024] Open
Abstract
Objective Fluorine-18 fluorodeoxyglucose ( 18 F-FDG) positron emission tomography/computed tomography (PET/CT) has gained attention as an emerging tool in case of suspicion of infection on spine, whether native or instrumented. However, the diagnostic performance of 18 F-FDG PET/CT in clinically occult low-grade surgical site infection (SSI) after spinal fusion, an important risk factor for pseudarthrosis, remains unknown. Methods We retrospectively identified all the presumed aseptic patients with pseudarthrosis confirmed by revision surgery who underwent preoperative 18 F-FDG PET/CT scans performed between April 2019 and November 2022. These patients were presumed aseptic because they did not have clinical signs or laboratory tests suggestive of SSI, preoperatively. The PET/CT images were analyzed in consensus by two nuclear medicine physicians blinded to the clinical, biological, and imaging information. Visual assessment of increased uptake around cage/intervertebral disk space (and/or hardware) higher than background recorded from the first normal adjacent vertebra was interpreted as positive. Image data were also quantitatively analyzed by the maximum standardized uptake value as an index of 18 F-FDG uptake, and the ratio between the uptake around cage/intervertebral disk space (and/or hardware) and background recorded from the first normal adjacent vertebra was calculated. The final diagnosis of infection was based on intraoperative cultures obtained during pseudarthrosis revision surgery. Results Thirty-six presumed aseptic patients with surgically confirmed pseudarthrosis after spinal fusion underwent preoperative 18 F-FDG PET/CT scans. Cultures of samples from revisions found that 20 patients (56%) were infected. The most frequent isolated bacterium was Cutibacterium acnes ( C. acnes ) in 15 patients (75%), followed by coagulase-negative staphylococci (CNS) in 7 patients (33%). Two patients had co-infections involving both C. acnes and CNS. Of the 36 PET/CT studied in this study, 12 scans were true-negative, 10 true-positive, 10 false-negative, and 4 false-positive. This resulted in sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of 50%, 75%, 71%, 55%, and 61%, respectively. Conclusion In presumed aseptic pseudarthrosis after spinal fusion, 18 F-FDG PET/CT offers good specificity (75%) but low sensitivity (50%) to identify occult SSI. The high prevalence (56%) of SSI, mostly caused by C. acnes (75%), found in our presumed aseptic cohort of patients supports the utility of systematic intraoperative cultures in revision cases for pseudarthrosis.
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Affiliation(s)
| | - Eric Lioret
- Department of Neurosurgery, Vinci Clinic, Tours, France
| | | | | | | | | | | | - Maja Ogielska
- Department of Infectious Diseases, Vinci Clinic, Tours, France
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Gonzalez GA, Porto G, Tecce E, Oghli YS, Miao J, O'Leary M, Chadid DP, Vo M, Harrop J. Advances in diagnosis and management of atypical spinal infections: A comprehensive review. NORTH AMERICAN SPINE SOCIETY JOURNAL 2023; 16:100282. [PMID: 37915965 PMCID: PMC10616400 DOI: 10.1016/j.xnsj.2023.100282] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/28/2023] [Accepted: 09/24/2023] [Indexed: 11/03/2023]
Abstract
Atypical spinal infections (ASIs) of the spine are a challenging pathology to management with potentially devastating morbidity and mortality. To identify patients with atypical spinal infections, it is important to recognize the often insidious clinical and radiographic presentations, in the setting of indolent and smoldering organism growth. Trending of inflammatory markers, and culturing of organisms, is essential. Once identified, the spinal infection should be treated with antibiotics and possibly various surgical interventions including decompression and possible fusion depending on spine structural integrity and stability. Early diagnosis of ASIs and immediate treatment of debilitating conditions, such as epidural abscess, correlate with fewer neurological deficits and a shorter duration of medical treatment. There have been great advances in surgical interventions and spinal fusion techniques for patients with spinal infection. Overall, ASIs remain a perplexing pathology that could be successfully treated with early diagnosis and immediate, appropriate medical, and surgical management.
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Affiliation(s)
- Glenn A. Gonzalez
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 909 Walnut St, Philadelphia, PA 19107, United States
| | - Guilherme Porto
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 909 Walnut St, Philadelphia, PA 19107, United States
| | - Eric Tecce
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 909 Walnut St, Philadelphia, PA 19107, United States
| | - Yazan Shamli Oghli
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 909 Walnut St, Philadelphia, PA 19107, United States
| | - Jingya Miao
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 909 Walnut St, Philadelphia, PA 19107, United States
| | - Matthew O'Leary
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 909 Walnut St, Philadelphia, PA 19107, United States
| | | | - Michael Vo
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 909 Walnut St, Philadelphia, PA 19107, United States
| | - James Harrop
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 909 Walnut St, Philadelphia, PA 19107, United States
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Omosor E, Milosavljevic E, Lawson E, Lopez-Gonzalez MA. Isolated cervical Cutibacterium acnes osteomyelitis in a patient with no primary source of infection - A case report and review of the literature. Surg Neurol Int 2023; 14:358. [PMID: 37941631 PMCID: PMC10629298 DOI: 10.25259/sni_542_2023] [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: 06/27/2023] [Accepted: 09/18/2023] [Indexed: 11/10/2023] Open
Abstract
Background Cervical vertebral osteomyelitis (CVO) is a rare pathology that leads to progressive osseous degradation and eventual loss of bone putting the patient at risk of devastating neurological injury in the event of bony collapse or instability. Cutibacterium acnes formerly called Propionibacterium acnes is rare, but within the last two decades has been an increasingly reported cause of osteomyelitis. The majority of C. acnes vertebral osteomyelitis cases have been reported in patients with a history of prior invasive procedures where direct contamination at the time of procedure was suspected as the underlying etiology. Case Description We report a unique case of an otherwise healthy 39-year-old male with no prior history of invasive procedures who presented with CVO secondary to C. acnes. He underwent surgical debridement and fusion in conjunction with antibiotic treatment. The patient recovered well and a 2-year follow-up with serial imaging showed no evidence of disease recurrence. Conclusion C. acnes is an under-recognized and under-reported etiology of spine infections. Clinicians should be aware of the pathological potential and atypical presentation of C. acnes vertebral osteomyelitis.
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Affiliation(s)
- Emmanuel Omosor
- Department of Neurosurgery, School of Medicine, Loma Linda University, Loma Linda, California, United States
| | - Elena Milosavljevic
- Department of Radiology, Loma Linda University Medical Center, Loma Linda, California, United States
| | - Edward Lawson
- Department of Neurosurgery, School of Medicine, Loma Linda University, Loma Linda, California, United States
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7
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Tai DBG, Lahr B, Suh GA, Berbari EF, Huddleston PM, Tande AJ. Defeating the Hidden Foe: Antibiotic Therapy and Clinical Outcomes of Cutibacterium acnes Spinal Implant Infections. Open Forum Infect Dis 2023; 10:ofad403. [PMID: 37559751 PMCID: PMC10407461 DOI: 10.1093/ofid/ofad403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 07/22/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Cutibacterium acnes can cause spinal implant infections. However, little is known about the optimal medical management and outcomes of C. acnes spinal implant infections (CSII). Our study aims to describe the management of patients with CSII and evaluate the clinical outcomes. METHODS We performed a retrospective cohort study of patients aged 18 years or older who underwent spinal fusion surgery with instrumentation between January 1, 2011, and December 31, 2020, and whose intraoperative cultures were positive for C. acnes. The primary outcome was treatment failure based on subsequent recurrence, infection with another organism, or unplanned surgery secondary to infection. RESULTS There were 55 patients with a median follow-up (interquartile range) of 2 (1.2-2.0) years. Overall, there were 6 treatment failures over 85.8 total person-years, for an annual rate of 7.0% (95% CI, 2.6%-15.2%). Systemic antibiotic treatment was given to 74.5% (n = 41) of patients for a median duration of 352 days. In the subgroup treated with systemic antibiotics, there were 4 treatment failures (annual rate, 6.3%; 95% CI, 1.7%-16.2%), all of which occurred while on antibiotic therapy. Two failures occurred in the subgroup without antibiotic treatment (annual rate, 8.8%; 95% CI, 1.1%-31.8%). CONCLUSIONS Our study found that the estimated annual treatment failure rate was slightly higher among patients who did not receive antibiotics. Of the 6 failures observed, 4 had recurrence of C. acnes either on initial or subsequent treatment failures. More studies are warranted to determine the optimal duration of therapy for CSII.
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Affiliation(s)
- Don Bambino Geno Tai
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, USA
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Brian Lahr
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Gina A Suh
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Elie F Berbari
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Paul M Huddleston
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Aaron J Tande
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Núñez-Pereira S, Benavent E, Ulldemolins M, Sobrino-Díaz B, Iribarren JA, Escudero-Sánchez R, Del Toro MD, Nodar A, Sorli L, Bahamonde A, Vilchez HH, Gasch O, Muñez E, Rodríguez-Montserrat D, García-País MJ, Haddad S, Sellarès-Nadal J, Murillo O, Rodríguez-Pardo D. Cutibacterium spp. Infections after Instrumented Spine Surgery Have a Good Prognosis Regardless of Rifampin Use: A Cross-Sectional Study. Antibiotics (Basel) 2023; 12:antibiotics12030518. [PMID: 36978385 PMCID: PMC10044575 DOI: 10.3390/antibiotics12030518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 02/25/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
Infection after spinal instrumentation (IASI) by Cutibacterium spp. is being more frequently reported. The aim of this study was to analyse the incidence, risk factors, clinical characteristics, and outcome of a Cutibacterium spp. IASI (CG) compared with non-Cutibacterium IASI (NCG) infections, with an additional focus on the role of rifampin in the treatment. All patients from a multicentre, retrospective, observational study with a confirmed IASI between January 2010 and December 2016 were divided into two groups: (CG and NCG) IASI. Baseline, medical, surgical, infection treatment, and follow-up data were compared for both groups. In total, 411 patients were included: 27 CG and 384 NCG. The CG patients were significantly younger. They had a longer median time to diagnosis (23 vs. 13 days) (p = 0.025), although 55.6% debuted within the first month after surgery. Cutibacterium patients were more likely to have the implant removed (29.6% vs. 12.8%; p = 0.014) and received shorter antibiotic regimens (p = 0.014). In 33% of Cutibacterium cases, rifampin was added to the baseline therapy. None of the 27 infections resulted in treatment failure during follow-up regardless of rifampin use. Cutibacterium spp. is associated with a younger age and may cause both early and late IASIs. In our experience, the use of rifampin to improve the outcome in the treatment of a Cutibacterium spp. IASI is not relevant since, in our series, none of the cases had therapeutic failure regardless of the use of rifampin.
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Affiliation(s)
- Susana Núñez-Pereira
- Spine Unit, Orthopaedic Surgery Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
- Correspondence: (S.N.-P.); (D.R.-P.); Tel.: +34-934893480 (S.N.-P)
| | - Eva Benavent
- Infectious Diseases Department, Hospital Universitari de Bellvitge, IDIBELL, Universitat de Barcelona, L’Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Marta Ulldemolins
- Infectious Diseases Department, Hospital Universitari de Bellvitge, IDIBELL, Universitat de Barcelona, L’Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Beatriz Sobrino-Díaz
- Department of Infectious Diseases, Hospital Regional Universitario Málaga, 29011 Málaga, Spain
| | - José A. Iribarren
- Infectious Diseases Department, Hospital Universitario Donostia, 20014 Gipuzkoa, Spain
| | - Rosa Escudero-Sánchez
- Infectious Disease Department, University Hospital Ramón y Cajal, 28034 Madrid, Spain
- CIBERINFEC, ISCIII-CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Av. de Monforte de Lemos, 5, 28029 Madrid, Spain
| | - María Dolores Del Toro
- CIBERINFEC, ISCIII-CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Av. de Monforte de Lemos, 5, 28029 Madrid, Spain
- Infectious Diseases Unit, Hospital Universitario Virgen Macarena, 41009 Seville, Spain
- Departamento de Medicina, Instituto de Biomedicina de Sevilla (IBiS), Universidad de Sevilla, 41009 Seville, Spain
| | - Andrés Nodar
- Infectious Diseases Unit, Internal Medicine Department, 36312 Vigo, Spain
- Instituto de Investigación Biomédica Galicia Sur, Hospital Álvaro Cunqueiro, 36312 Vigo, Spain
| | - Luisa Sorli
- CIBERINFEC, ISCIII-CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Av. de Monforte de Lemos, 5, 28029 Madrid, Spain
- Infectious Diseases Department, Hospital del Mar, 08003 Barcelona, Spain
- Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), CEXS-Universitat Pompeu Fabra, 08003 Barcelona, Spain
| | - Alberto Bahamonde
- Department of Internal Medicine-Infectious Diseases, Hospital Universitario del Bierzo, 24411 Ponferrada, Spain
| | - Helem H. Vilchez
- Infectious Diseases Unit, Department of Internal Medicine, Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain
| | - Oriol Gasch
- Infectious Diseases Department, Hospital Parc Tauli de Sabadell, University Autonoma of Barcelona, 08208 Barcelona, Spain
| | - Elena Muñez
- Infectious Diseases Unit, Internal Medicine Department, Hospital Puerta de Hierro-Majadahonda, 28222 Madrid, Spain
| | | | - María José García-País
- Infectious Disease Unit and Microbiology Departments, Hospital Universitario Lucus Augusti, 27003 Lugo, Spain
| | - Sleiman Haddad
- Spine Unit, Orthopaedic Surgery Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Julia Sellarès-Nadal
- Infectious Diseases Department, Vall d’Hebron, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain
- Medicine Department, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
| | - Oscar Murillo
- Infectious Diseases Department, Hospital Universitari de Bellvitge, IDIBELL, Universitat de Barcelona, L’Hospitalet de Llobregat, 08907 Barcelona, Spain
- CIBERINFEC, ISCIII-CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Av. de Monforte de Lemos, 5, 28029 Madrid, Spain
| | - Dolors Rodríguez-Pardo
- CIBERINFEC, ISCIII-CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Av. de Monforte de Lemos, 5, 28029 Madrid, Spain
- Infectious Diseases Department, Vall d’Hebron, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain
- Medicine Department, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
- Correspondence: (S.N.-P.); (D.R.-P.); Tel.: +34-934893480 (S.N.-P)
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Gelderman SJ, Faber C, Kampinga GA, Jutte PC, Ploegmakers JJW, Glaudemans AWJM, Wouthuyzen-Bakker M. A high prevalence of Cutibacterium acnes infections in scoliosis revision surgery, a diagnostic and therapeutic dilemma. Spine Deform 2023; 11:319-327. [PMID: 36282416 PMCID: PMC9970938 DOI: 10.1007/s43390-022-00599-1] [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: 09/30/2021] [Accepted: 10/01/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE To investigate if serum inflammatory markers or nuclear imaging can accurately diagnose a chronic spinal instrumentation infection (SII) prior to surgery. METHODS All patients who underwent revision of spinal instrumentation after a scoliosis correction between 2017 and 2019, were retrospectively evaluated. The diagnostic accuracy of serum C-reactive protein (CRP) and Erythrocyte Sedimentation Rate (ESR), 18F-fluorodeoxyglucose positron emission tomography combined with computed tomography (FDG-PET/CT) and Technetium-99m-methylene diphosphonate (99mTc-MDP) 3-phase bone scintigraphy (TPBS) to diagnose infection were studied. Patients with an acute infection or inadequate culture sampling were excluded. SII was diagnosed if ≥ 2 of the same microorganism(s) were isolated from intra-operative tissue cultures. RESULTS 30 patients were included. The indication for revision surgery was pseudoarthrosis in the majority of patients (n = 15). 22 patients (73%) were diagnosed with SII. In all infected cases, Cutibacterium acnes was isolated, including 5 cases with a polymicrobial infection. The majority of patients had low inflammatory parameters preoperatively. For CRP > 10.0 mg/L, the sensitivity was 9.1% and specificity 100%; for ESR > 30 mm/h, the sensitivity was 9.1% and specificity 100%. The diagnostic accuracy for nuclear imaging was 64% for the FDG-PET/CT and 67% for the TPBS to diagnose infection. CONCLUSIONS The prevalence of SII in patients undergoing revision spinal surgery is high, with Cutibacterium acnes as the main pathogen. No diagnostic tests could be identified that could accurately diagnose or exclude SII prior to surgery. Future studies should aim to find more sensitive diagnostic modalities to detect low-grade inflammation.
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Affiliation(s)
- Stefan J. Gelderman
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Christhoper Faber
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Greetje A. Kampinga
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Paul C. Jutte
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Joris J. W. Ploegmakers
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Andor W. J. M. Glaudemans
- Medical Imaging Center, Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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10
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Passerini M, Maamari J, Geno Tai D, Patel R, Tande A, Temesgen Z, Berbari E. Cutibacterium acnes in spine tissue: characteristics and outcomes of non-hardware-associated vertebral osteomyelitis. J Bone Jt Infect 2023; 8:143-149. [PMID: 37187898 PMCID: PMC10176096 DOI: 10.5194/jbji-8-143-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 03/25/2023] [Indexed: 05/17/2023] Open
Abstract
Cutibacterium acnes isolation from spine tissue can be challenging because the organism can represent a contaminant. There is a paucity of data regarding the role of C. acnes in non-hardware-associated vertebral osteomyelitis (VO). Herein we evaluate the clinical and microbiological characteristics, treatment, and outcome of patients with C. acnes VO. Data were retrospectively collected from adults with a positive spine culture for C. acnes at Mayo Clinic, Rochester (MN), from 2011 to 2021. Patients with spinal hardware and polymicrobial infections were excluded. Of the subjects, 16 showed radiological and clinical findings of VO: 87.5 % were male, the average age was 58 years (±15 SD), and back pain was the predominant symptom. Of the lesions, 89.5 % involved the thoracic spine. Of the subjects, 69 % had experienced an antecedent event at the site of VO. In five subjects, C. acnes was isolated after 7 d of anaerobic culture incubation. Thirteen subjects were treated with parenteral β-lactams, and three with oral antimicrobials, without any evidence of recurrence. Twenty-one subjects were not treated for VO, as C. acnes was considered a contaminant; at follow-up, none had evidence of progressive disease. C. acnes should be part of microbiological differential diagnosis in patients with suspected VO, especially in the context of a prior spinal procedure. Anaerobic spine cultures should undergo prolonged incubation to enable recovery of C. acnes. C. acnes VO may be managed with oral or parenteral antimicrobial therapy. Without clinical and radiological evidence of VO, a single positive culture of C. acnes from spine tissue frequently represents contaminants.
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Affiliation(s)
- Matteo Passerini
- Division of Public Health, Infectious Diseases, and Occupational
Medicine, Mayo Clinic, Rochester, MN, USA
| | - Julian Maamari
- Division of Public Health, Infectious Diseases, and Occupational
Medicine, Mayo Clinic, Rochester, MN, USA
| | - Don Bambino Geno Tai
- Division of Infectious Diseases and International Medicine, Department
of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Robin Patel
- Division of Clinical Microbiology, Department of Laboratory Medicine
and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Aaron J. Tande
- Division of Public Health, Infectious Diseases, and Occupational
Medicine, Mayo Clinic, Rochester, MN, USA
| | - Zelalem Temesgen
- Division of Public Health, Infectious Diseases, and Occupational
Medicine, Mayo Clinic, Rochester, MN, USA
| | - Elie F. Berbari
- Division of Public Health, Infectious Diseases, and Occupational
Medicine, Mayo Clinic, Rochester, MN, USA
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11
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Clinical relevance of occult infections in spinal pseudarthrosis revision. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2022; 12:100172. [PMID: 36185342 PMCID: PMC9520268 DOI: 10.1016/j.xnsj.2022.100172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 09/10/2022] [Accepted: 09/10/2022] [Indexed: 11/30/2022]
Abstract
Background Occult infections in spinal pseudarthrosis revisions have been reported in the literature, but the relevance of such an infection on patient outcomes is unknown. We aimed to elucidate clinical outcomes and re-revision risks between patients with and without occult infections in spinal revision surgery for pseudarthrosis. Methods In this matched case-control study, we identified 128 patients who underwent thoracolumbar revision surgery from 2014–2019 for pseudarthrosis of the spine. Among them, 13 (10.2%) revealed an occult infection (defined by at least two positive intraoperative tissue samples with the same pathogen), and nine of these 13 were available for follow-up. We selected 18 of the 115 controls using a 2:1 fuzzy matching based on fusion length and length of follow-up. The patients were followed up to assess subsequent re-revision surgeries and the following postoperative patient-reported outcome measures (PROMs): overall satisfaction, Oswestry Disability Index, 5-level EQ-5D, and Short Form 36. Results Patient characteristics, surgical data, and length of follow-up were equal between both study groups. The rate of re-revision free survival after the initial pseudarthrosis revision surgery was higher in the occult infection group (77.8%) than the non-infectious controls (44.4%), although not significantly (0.22). The total number of re-revision surgeries, including re-re-revisions, was thirteen (in ten patients) in the control and two (in two patients) in the occult infection group (p = 0.08) after a median follow-up of 24 months (range 13-75). Four cases in the control group underwent re-revision for pseudarthrosis compared to none in the infected group. Satisfactory scores were recorded in all PROMs, with similar scores between the two groups. Conclusions The presence of an occult infection accompanying spinal pseudarthrosis revision was not inferior to non-infected pseudarthrosis revisions in a matched, small sample size cohort study. This may be explained due to the possibility of targeted treatment of the identified cause of pseudarthrosis.
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12
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El Yaagoubi Y, Loret JE, Lioret E, Thomas C, Simonneau A, Vinikoff L, Prunier-Aesch C, Chetanneau A, Philippe L, Ogielska M, Bernard L. 18F-NaF PET/CT in Presumed Aseptic Pseudarthrosis after Spinal Fusion: Correlation with Findings at Revision Surgery and Intraoperative Cultures. World J Nucl Med 2022; 21:302-313. [DOI: 10.1055/s-0042-1750400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Abstract
Background Conventional imaging is useful to assess interbody fusion by showing complete trabecular bony bridging, but has a low positive predictive value for pseudarthrosis. Because alterations of bone metabolism may precede structural anatomical changes on computed tomography (CT), we aimed to investigate the ability of fluorine 18 sodium fluoride positron emission tomography/computed tomography (18F-NaF PET/CT) to identify pseudarthrosis after spinal fusion using surgical revision as the reference standard.
Methods We retrospectively reviewed 18F-NaF PET/CT scans performed between February 2019 and September 2020 in patients experiencing pain after spinal fusion. We included the 18 patients who underwent revision surgery for suspicion of pseudarthrosis. Five consecutive patients who were clearly fused on CT served as the control group.
Results In the revision surgery group (n=18), visual assessment by 18F-NaF PET/CT revealed that all 22 cages with an increased 18F-NaF uptake around intercorporal fusion material had mobility at revision surgery, whereas none of the fused patients (n=5) showed uptake around cage/intervertebral disk space. Among the 18 patients with presumed aseptic pseudarthrosis, intraoperative cultures revealed surgical site infection (SSI) caused by Cutibacterium acnes (C. acnes) in seven patients (38.9%). There was a statistically significant difference in standardized uptake values and uptake ratios between the revision surgery and control groups (p=5.3× 10−6 and p=0.0002, respectively).
Conclusions 18F-NaF PET/CT imaging appeared as a useful tool to identify pseudarthrosis following spinal fusion. The unexpectedly high prevalence (38.9%) of SSI caused by C. acnes found in presumed aseptic patients supports the utility of intraoperative cultures in revision cases for pseudarthrosis, even without preoperative clinical suspicion of SSI.
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Affiliation(s)
- Yacine El Yaagoubi
- Department of Nuclear Medicine, Vinci Clinic, Alexandre Minkowski, Chambray-lès-Tours, France
| | | | - Eric Lioret
- Department of Neurosurgery, Vinci Clinic, Alexandre Minkowski, Chambray-lès-Tours, France
| | - Clément Thomas
- Department of Neurosurgery, Vinci Clinic, Alexandre Minkowski, Chambray-lès-Tours, France
| | - Adrien Simonneau
- Department of Neurosurgery, NCT+ Clinic, Saint-Cyr-sur-Loire, France
| | - Laurent Vinikoff
- Department of Neurosurgery, NCT+ Clinic, Saint-Cyr-sur-Loire, France
| | - Caroline Prunier-Aesch
- Department of Nuclear Medicine, Vinci Clinic, Alexandre Minkowski, Chambray-lès-Tours, France
| | - Alain Chetanneau
- Department of Nuclear Medicine, Vinci Clinic, Alexandre Minkowski, Chambray-lès-Tours, France
| | - Laurent Philippe
- Department of Nuclear Medicine, Vinci Clinic, Alexandre Minkowski, Chambray-lès-Tours, France
| | - Maja Ogielska
- Department of Infectious Diseases, Vinci Clinic, Alexandre Minkowski, Chambray-lès-Tours, France
| | - Louis Bernard
- Department of Infectious Diseases, Bretonneau University Hospital, Tonnellé, Tours, France
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13
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Fast and Sensitive Multiplex Real-Time Quantitative PCR to Detect Cutibacterium Periprosthetic Joint Infections. J Mol Diagn 2022; 24:666-673. [PMID: 35364323 DOI: 10.1016/j.jmoldx.2022.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 01/31/2022] [Accepted: 03/04/2022] [Indexed: 12/26/2022] Open
Abstract
Diagnosis of Cutibacterium periprosthetic joint infections (PJIs) is challenging due to a long cultivation time of up to 14 days. Faster culture-independent diagnosis would improve patient care with early and accurate treatment. Specific primers and probes were designed for Cutibacterium acnes, Cutibacterium avidum, and Cutibacterium granulosum and evaluated in a multiplex TaqMan real-time quantitative PCR (qPCR) format on 57 skin swabs and 20 culture-negative cerebrospinal fluid samples. The multiplex qPCR was tested in a PJI cohort of 41 sonication fluid samples from removed implants infected with different pathogens. All five culture-positive Cutibacterium PJIs were detected with the corresponding Cutibacterium-specific probe (100% positive percent agreement). The multiplex qPCR additionally detected C. avidum in two PJI sonication fluid samples that were diagnosed as Staphylococcus species infections according to culture (95% negative percent agreement). The new multiplex qPCR can provide a Cutibacterium PJI diagnosis within 1 day, allowing early and accurate antibiotic treatment. A prospective diagnostic trial in PJI with a high number of Cutibacterium species infections (shoulder PJI) is needed for further evaluation.
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14
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Garcia DR, Berns EM, Spake CSL, Mayfield C, Dockery DM, Vishwanath N, Leong J, Glasser J, Barrett C, Green A, Antoci V, Daniels AH, Born CT. Silver carboxylate-doped titanium dioxide-polydimethylsiloxane coating decreases Cutibacterium acnes adherence and biofilm formation on polyether ether ketone. Spine J 2022; 22:495-503. [PMID: 34666180 DOI: 10.1016/j.spinee.2021.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/26/2021] [Accepted: 09/28/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Cutibacterium acnes (C. acnes) is a gram-positive facultative anaerobe found in the deep sebaceous follicles of the skin on the shoulder and back. C. acnes has been increasingly recognized as a pathogen in spinal surgical site infection (SSI) especially in the presence of instrumentation. PURPOSE This study assesses whether a silver carboxylate-doped titanium dioxide-polydimethylsiloxane (TiO2-PDMS) coating can decrease C. acnes adherence and biofilm formation on PEEK and four other commonly used spinal implant materials, stainless steel, cobalt chromium, titanium, and titanium alloy. STUDY DESIGN We compared the adherence of C. acnes over 24 hours between uncoated, 95:5 TiO2 to PDMS ratio with 10× silver carboxylate coating and a 100% silver carboxylate coating on each implant material, which were uniformly saw cut and sterilized. Implants were then subjected to scanning electron microscopy (SEM) and confocal scanning laser microscopy (CSLM). METHODS Samples were coated using 95:5 TiO2-PDMS 10× silver carboxylate, 100% silver carboxylate, or left uncoated. C. acnes was applied onto the samples and allowed to adhere for periods of 4, 8, 12, 16, or 20 hours. Nonadherent bacteria were then washed from the samples. These samples were then allowed to continue incubating for a total of 24 hours. SEM and confocal laser scanning microscope were used to visualize all samples for the presence of biofilm and quantification of C. acnes adherence at each time point. RESULTS The 95:5 TiO2-PDMS 10× silver carboxylate coating was able to significantly decrease C. acnes adherence on PEEK after 8, 12, 16, and 20 hours of adherence. No statistical difference was found between the 95:5 TiO2-PDMS 10× silver carboxylate coating and the 100% silver carboxylate positive control. We previously observed extensive C. acnes biofilm formation on uncoated PEEK, but none on PEEK coated with either the 95:5 TiO2-PDMS 10× silver carboxylate or 100% Ag coating . Furthermore, no biofilm formation was observed on stainless steel, cobalt chromium, titanium, and titanium alloy coated with 95:5 TiO2-PDMS 10× silver carboxylate or 100% Ag coating. CONCLUSION A 95:5 TiO2-PDMS 10× silver carboxylate coating decreases C. acnes adhesion and prevents biofilm formation on PEEK and other common orthopedic implant materials. CLINICAL SIGNIFICANCE A 95:5 TiO2-PDMS 10× silver carboxylate coating may help decrease spinal SSI due to C. acnes, especially in procedures with instrumentation.
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Affiliation(s)
- Dioscaris R Garcia
- The Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA; Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, RI, USA.
| | - Ellis M Berns
- The Warren Alpert Medical School of Brown University, Providence, RI, USA; Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, RI, USA
| | - Carole S L Spake
- The Warren Alpert Medical School of Brown University, Providence, RI, USA; Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, RI, USA
| | - Cory Mayfield
- The Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA; Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, RI, USA
| | - Dominique M Dockery
- The Warren Alpert Medical School of Brown University, Providence, RI, USA; Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, RI, USA
| | - Neel Vishwanath
- The Warren Alpert Medical School of Brown University, Providence, RI, USA; Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, RI, USA
| | - Jacqueline Leong
- The Warren Alpert Medical School of Brown University, Providence, RI, USA; Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, RI, USA
| | - Jillian Glasser
- Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, RI, USA
| | - Caitlin Barrett
- Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, RI, USA
| | - Andrew Green
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Valentin Antoci
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA; Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, RI, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Christopher T Born
- The Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA; Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, RI, USA
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15
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Indolent Infection After Lumbar Interbody Fusion: An Under-recognized Cause of Pseudarthrosis, Which Can Be Successfully Treated With Anterior Revision Fusion. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202203000-00005. [PMID: 35266911 PMCID: PMC8893294 DOI: 10.5435/jaaosglobal-d-21-00259] [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: 10/12/2021] [Accepted: 01/13/2022] [Indexed: 11/18/2022]
Abstract
Introduction: Methods: Results: Discussion:
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16
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Applebaum A, Nessim A, Cho W. Modic Change: An Emerging Complication in the Aging Population. Clin Spine Surg 2022; 35:12-17. [PMID: 33769981 DOI: 10.1097/bsd.0000000000001168] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 02/24/2021] [Indexed: 01/04/2023]
Abstract
STUDY DESIGN This was a literature review. OBJECTIVE The objective of this study was to review the pathogenesis, prevalence, clinical associations, diagnostic modalities, and treatment options for patients with lower back pain (LBP) associated with Modic change (MC). SUMMARY OF BACKGROUND DATA Vertebral body endplates are located between the intervertebral disk and adjacent vertebral body. Despite their crucial roles in nutrition and biomechanical stability, vertebral endplates are extremely susceptible to mechanical failure. Studies examining the events leading to disk degeneration have shown that failure often begins at the endplates. Endplate degeneration with subchondral bone marrow changes were originally noticed on magnetic resonance imaging. These magnetic resonance imaging signal changes were classified as MC. METHODS A literature review was conducted on the history, etiology, risk factors, diagnostic modalities, and treatment of LBP with MC. RESULTS Type 1 MC refers to the presence of increased vascularization and bone marrow edema within the vertebral body. Type 2 MC involves fatty marrow replacement within the vertebral body. Type 3 MC reflects subchondral bone sclerosis. Despite the original classification, research has supported the notion that MCs possess a transitional nature. Furthermore, type 1 MCs have been strongly associated with inflammation and severe LBP, while types 2 and 3 tend to be more stable and demonstrate less refractory pain. With a strong association to LBP, understanding the etiology of MC is crucial to optimal treatment planning. Various etiologic theories have been proposed including autoimmunity, mechanics, infection, and genetic factors. CONCLUSIONS With the aging nature of the population, MC has emerged as an extremely prevalent issue. Research into the pathogenesis of MC is important for planning preventative and therapeutic strategies. Such strategies may include rehabilitation, surgical fixation, stabilization, steroid or cement injection, or antibiotics. Improved diagnostic methods in clinical practice are thus critical to properly identify patients suffering from MC, plan early intervention, and hasten return to functioning.
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Affiliation(s)
- Ariella Applebaum
- Department of Orthopedic Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
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17
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A new immunometabolic perspective of intervertebral disc degeneration. Nat Rev Rheumatol 2022; 18:47-60. [PMID: 34845360 DOI: 10.1038/s41584-021-00713-z] [Citation(s) in RCA: 152] [Impact Index Per Article: 76.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2021] [Indexed: 12/12/2022]
Abstract
Intervertebral disc (IVD) degeneration is a common finding on spine imaging that increases in prevalence with age. IVD degeneration is a frequent cause of low back pain, which is a leading cause of disability. The process of IVD degeneration consists of gradual structural change accompanied by severe alterations in metabolic homeostasis. IVD degeneration, like osteoarthritis, is a common comorbidity in patients with obesity and type 2 diabetes mellitus, two metabolic syndrome pathological conditions in which adipokines are important promoters of low-grade inflammation, extracellular matrix degradation and fibrosis. Impairment in white adipose tissue function, due to the abnormal fat accumulation in obesity, is characterized by increased production of specific pro-inflammatory proteins such as adipokines by white adipose tissue and of cytokines such as TNF by immune cells of the stromal compartment. Investigations into the immunometabolic alterations in obesity and type 2 diabetes mellitus and their interconnections with IVD degeneration provide insights into how adipokines might affect the pathogenesis of IVD degeneration and impair IVD function and repair. Toll-like receptor-mediated signalling has also been implicated as a promoter of the inflammatory response in the metabolic alterations associated with IVD and is thus thought to have a role in IVD degeneration. Pathological starvation, obesity and adipokine dysregulation can result in immunometabolic alterations, which could be targeted for the development of new therapeutics.
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18
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Dockery DM, Allu S, Vishwanath N, Li T, Berns E, Glasser J, Spake CSL, Antoci V, Born CT, Garcia DR. Review of Pre-Operative Skin Preparation Options Based on Surgical Site in Orthopedic Surgery. Surg Infect (Larchmt) 2021; 22:1004-1013. [PMID: 34388024 DOI: 10.1089/sur.2021.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Surgical site infections (SSIs) are a primary contributor to surgical morbidity and mortality, causing a substantial financial burden on the healthcare system. Specifically, Cutibacterium acnes contributes greatly to infections in the shoulder and spine regions. Prevention of infection is crucial to improve patient outcomes and reduce costs. This article reviews current surgical skin preparation solutions, the unique distribution of organisms at common orthopedic surgical sites, and recommends solutions based on surgical location. Methods: A search of electronic databases (PubMed, MEDLINE, and Embase) was conducted for relevant literature until December 2020. Sources were compiled based on title and abstract, then full texts were read for possible inclusion. This review summarizes the most recent publications in the field of SSIs and preparation solutions. Results: The mechanism and efficacy of alcohol-, iodine-, and chlorhexidine-based preparations were reviewed, along with experimental preparations. This article identifies common colonization patterns for the shoulder, elbow, hip, knee, spine, foot, and ankle, and discusses recommendations for preparations based on current evidence. Recommendations: For shoulder and elbow operations, we recommend ChloraPrep™ (CareFusion, BD, El Paso, TX), DuraPrep™ (3M Health Care, St. Paul, MN), or Betadine® applied with 4 × 4 gauze sponge, three-day pre-operative benzyl peroxide, and application of 3% hydrogen peroxide before skin preparation. For the hip and knee, we recommend application of 2% chlorhexidine gluconate (CHG) cloth the night before and morning of surgery and either DuraPrep or iodine-alcohol skin prep prior to surgery. For spine surgeries, we recommended ChloraPrep. For foot and ankle, our recommendations are: ChloraPrep or DuraPrep, submersion of foot in 70% ethanol/10% isopropyl alcohol for five minutes prior to procedure, application with a bristled brush, and a second vigorous scrub with 4 × 4 soaked gauze. Conclusions: The current surgical skin preparations have both benefits and drawbacks. We recommend that orthopedic surgeons choose a skin preparation based on surgical site and prevalence of unique skin flora there.
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Affiliation(s)
- Dominique M Dockery
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Sai Allu
- Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA
| | - Neel Vishwanath
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Troy Li
- Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA
| | - Ellis Berns
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Jillian Glasser
- Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Carole S L Spake
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Valentin Antoci
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA.,Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Christopher T Born
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA.,Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Dioscaris R Garcia
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Weiss Center for Orthopaedic Trauma Research, Rhode Island Hospital, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA.,Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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19
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Gilligan CJ, Cohen SP, Fischetti VA, Hirsch JA, Czaplewski LG. Chronic low back pain, bacterial infection and treatment with antibiotics. Spine J 2021; 21:903-914. [PMID: 33610802 DOI: 10.1016/j.spinee.2021.02.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 02/14/2021] [Accepted: 02/15/2021] [Indexed: 02/03/2023]
Abstract
The contribution of bacterial infection to chronic low back pain and its treatment with antibiotics have generated considerable controversy in literature. If efficacious, antibiotics have the potential to transform the treatment of chronic low back pain in a significant subset of patients. Some microbiology studies of disc tissue from patients with CLBP have shown that bacteria are present, most likely due to infection, while others conclude they are absent or if found, it is due to surgical contamination. Clinical studies testing the efficacy of oral antibiotics to treat CLBP have either shown that the treatment is efficacious leading to significantly reduced pain and disability or that their effect is modest and not clinically significant. Critical review of the literature on CLBP, bacterial infection and treatment with antibiotics identified five well-designed and executed microbiology studies characterizing bacteria in disc samples that demonstrate that bacteria do infect herniated disc tissue, but that the bacterial burden is low and may be below the limits of detection in some studies. Two randomized, controlled clinical trials evaluating oral antibiotics in patients with CLBP indicate that for certain subsets of patients, the reduction in pain and disability achieved with antibiotic therapy may be significant. In patients for whom other therapies have failed, and who might otherwise progress to disc replacement or fusion surgery, antibiotic therapy may well be an attractive option to reduce the individual suffering associated with this debilitating condition. Additional clinical research is recommended to refine the selection of patients with CLBP caused or complicated by bacterial infection and most likely to respond to antibiotics, to optimize antibiotic therapy to maximize patient benefit, to minimize and manage side effects, and to address legitimate concerns about antibiotic stewardship.
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Affiliation(s)
- Christopher J Gilligan
- Brigham and Women's Hospital, Department of Anesthesiology, Perioperative and Pain Medicine, Boston, MA, USA
| | - Steven P Cohen
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 550 N. Broadway, Ste 301, Baltimore, MD 21029, USA; Department of Anesthesiology, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889, USA
| | - Vincent A Fischetti
- Laboratory of Bacterial Pathogenesis and Immunology, The Rockefeller University, New York, New York
| | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Lloyd G Czaplewski
- Persica Pharmaceuticals Ltd, 7 Denne Hill Business Centre, Womenswold, Canterbury, Kent, CT4 6HD, UK.
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20
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Brüggemann H, Salar-Vidal L, Gollnick HPM, Lood R. A Janus-Faced Bacterium: Host-Beneficial and -Detrimental Roles of Cutibacterium acnes. Front Microbiol 2021; 12:673845. [PMID: 34135880 PMCID: PMC8200545 DOI: 10.3389/fmicb.2021.673845] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 04/29/2021] [Indexed: 12/18/2022] Open
Abstract
The bacterial species Cutibacterium acnes (formerly known as Propionibacterium acnes) is tightly associated with humans. It is the dominant bacterium in sebaceous regions of the human skin, where it preferentially colonizes the pilosebaceous unit. Multiple strains of C. acnes that belong to phylogenetically distinct types can co-exist. In this review we summarize and discuss the current knowledge of C. acnes regarding bacterial properties and traits that allow host colonization and play major roles in host-bacterium interactions and also regarding the host responses that C. acnes can trigger. These responses can have beneficial or detrimental consequences for the host. In the first part of the review, we highlight and critically review disease associations of C. acnes, in particular acne vulgaris, implant-associated infections and native infections. Here, we also analyse the current evidence for a direct or indirect role of a C. acnes-related dysbiosis in disease development or progression, i.e., reduced C. acnes strain diversity and/or the predominance of a certain phylotype. In the second part of the review, we highlight historical and recent findings demonstrating beneficial aspects of colonization by C. acnes such as colonization resistance, immune system interactions, and oxidant protection, and discuss the molecular mechanisms behind these effects. This new insight led to efforts in skin microbiota manipulation, such as the use of C. acnes strains as probiotic options to treat skin disorders.
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Affiliation(s)
| | - Llanos Salar-Vidal
- Department of Clinical Microbiology, Fundacion Jimenez Diaz University Hospital, Madrid, Spain
| | - Harald P. M. Gollnick
- Department of Dermatology and Venerology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Rolf Lood
- Division of Infection Medicine, Department of Clinical Sciences, Lund University, Lund, Sweden
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21
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Occult infection in pseudarthrosis revision after spinal fusion. Spine J 2021; 21:370-376. [PMID: 33080375 DOI: 10.1016/j.spinee.2020.10.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 09/22/2020] [Accepted: 10/13/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Pseudarthrosis after attempted spinal fusion is yet not sufficiently understood and presents a surgical challenge. Occult infections are sometimes observed in patients with pseudarthrosis and no inflammatory signs of infection. The prevalence of such occult infection and its association with patient demographics and inflammatory markers are largely unknown. PURPOSE To determine the prevalence of unexpected low-grade infection in spinal pseudarthrosis revision surgery, and to evaluate whether such infection is associated with patient demographics and inflammatory markers. STUDY DESIGN Retrospective observational study. PATIENT SAMPLE One-hundred-and-twenty-eight patients who underwent thoracolumbar revision surgery due to presumed aseptic pseudarthrosis after spinal instrumentation. OUTCOME MEASURES Culture-positive infections or noninfectious pseudarthrosis. METHODS Samples were routinely taken for microbiological examination from all adults (n=152) who underwent revision surgery for presumed aseptic thoracolumbar pseudarthrosis between 2014 and 2019. A full intraoperative microbiological workup (at least three intraoperative tissue samples) was done for 128 (84%) patients, and these patients were included in further analyses. Patient characteristics, medical history, inflammatory markers, and perioperative data were compared between those with and without microbiologically-confirmed infection based on samples obtained during pseudarthrosis revision. RESULTS The microbiological workup confirmed infection in 13 of 128 cases (10.2%). The predominant pathogen was Cutibacterium acnes (46.2%), followed by coagulase-negative staphylococci (38.5%). The presence of infection was associated with the body mass index (30.9±4.7 kg/m2 [infected] vs. 28.2±5.6 kg/m2 [controls], p=.049), surgery in the thoracolumbar region (46% vs. 18%, p=.019), and a slightly higher serum C-reactive protein level on admission (9.4±8.0 mg/L vs. 5.7±7.1 mg/L, p=.031). Occult infection was not associated with age, sex, prior lumbar surgeries, number of fused lumbar levels, American Society of Anesthesiologist score, Charlson Comorbidity Index, presence of diabetes mellitus, and smoking status. CONCLUSIONS Occult infections were found in 10% of patients undergoing pseudarthrosis revision after spinal fusion, even without preoperative clinical suspicion. Occult infection was associated with higher body mass index, fusions including the thoracolumbar junction, and slightly higher C-reactive protein levels. Intraoperative microbiological samples should be routinely obtained to exclude or identify occult infection in all revision surgeries for symptomatic pseudarthrosis of the spine, as this information can be used to guide postoperative antibiotic treatment.
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Bivona LJ, Camacho JE, Usmani F, Nash A, Bruckner JJ, Hughes M, Bhandutia AK, Koh EY, Banagan KE, Gelb DE, Ludwig SC. The Prevalence of Bacterial Infection in Patients Undergoing Elective ACDF for Degenerative Cervical Spine Conditions: A Prospective Cohort Study With Contaminant Control. Global Spine J 2021; 11:13-20. [PMID: 32875844 PMCID: PMC7734272 DOI: 10.1177/2192568219888179] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
STUDY DESIGN Prospective cohort study. OBJECTIVES To determine the prevalence of bacterial infection, with the use of a contaminant control, in patients undergoing anterior cervical discectomy and fusion (ACDF). METHODS After institutional review board approval, patients undergoing elective ACDF were prospectively enrolled. Samples of the longus colli muscle and disc tissue were obtained. The tissue was then homogenized, gram stained, and cultured in both aerobic and anaerobic medium. Patients were classified into 4 groups depending on culture results. Demographic, preoperative, and postoperative factors were evaluated. RESULTS Ninety-six patients were enrolled, 41.7% were males with an average age of 54 ± 11 years and a body mass index of 29.7 ± 5.9 kg/m2. Seventeen patients (17.7%) were considered true positives, having a negative control and positive disc culture. Otherwise, no significant differences in culture positivity was found between groups of patients. However, our results show that patients were more likely to have both control and disc negative than being a true positive (odds ratio = 6.2, 95% confidence interval = 2.5-14.6). Propionibacterium acnes was the most commonly identified bacteria. Two patients with disc positive cultures returned to the operating room secondary to pseudarthrosis; however, age, body mass index, prior spine surgery or injection, postoperative infection, and reoperations were not associated with culture results. CONCLUSION In our cohort, the prevalence of subclinical bacterial infection in patients undergoing ACDF was 17.7%. While our rates exclude patients with positive contaminant control, the possibility of contamination of disc cultures could not be entirely rejected. Overall, culture results did not have any influence on postoperative outcomes.
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Affiliation(s)
- Louis J. Bivona
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jael E. Camacho
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Farooq Usmani
- Department of General Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Alysa Nash
- Department of Orthopaedics, University of North Carolina at Chapel Hill, NC, USA
| | - Jacob J. Bruckner
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Meghan Hughes
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Amit K. Bhandutia
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Eugene Y. Koh
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kelley E. Banagan
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Daniel E. Gelb
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Steven C. Ludwig
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA,Steven C. Ludwig, Department of Orthopaedics, University of Maryland, 110 South Paca Street, 6th Floor, Suite 300, Baltimore, MD 21201, USA.
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Ramos O, Speirs JN, Danisa O. Lumbar Discitis and Osteomyelitis After a Spinal Stem Cell Injection?: A Case Report and Literature Review. JBJS Case Connect 2020; 10:e1900636. [PMID: 32773702 DOI: 10.2106/jbjs.cc.19.00636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
CASE A 32-year-old man developed lumbar discitis and osteomyelitis after receiving a cell-based injection for the treatment of degenerative disc disease. Initial cultures were negative, but he continued to worsen, and a repeat set of cultures was taken. On day 10, Cutibacterium acnes was isolated. He was then successfully treated with 12 weeks of intravenous antibiotics. CONCLUSIONS There is minimal regulation on the preparation or administration of cell-based interventions. It is important to consider slow growing organisms such as C. acnes in patients presenting with spinal infection with insidious onset after these treatments.
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Affiliation(s)
- Omar Ramos
- 1Department of Orthopaedic Surgery, Loma Linda University, Loma Linda, California
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