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Bruyninckx S, Metsemakers WJ, Depypere M, Henckaerts L, van den Hout E, Onsea J, Ghijselings S, Vles GF. Local antibiotic delivery via intra-articular catheter infusion for the treatment of periprosthetic joint infection: a systematic review. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05341-2. [PMID: 38691147 DOI: 10.1007/s00402-024-05341-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 04/14/2024] [Indexed: 05/03/2024]
Abstract
INTRODUCTION There is an increasing interest in the use of intra-articular (IA) antibiotic infusion as a stand-alone or adjuvant therapy to standard revision surgery for periprosthetic joint infection (PJI). The objective of this systematic review is to evaluate the evidence with respect to this up-and-coming treatment modality. METHODS A systematic review of studies published until April 2023 was conducted using PubMed, Embase, MEDLINE and Cochrane databases. Quality assessment was performed with the National Institute of Health quality assessment tool. Inclusion criteria were adult patients (≥ 18 years) with a mean follow-up of ≥ 11 months and a score ≥ 6 on the National Institute of Health quality assessment tool. Primary outcome was eradication of infection. RESULTS 15 articles, encompassing 631 PJIs in 626 patients, were included in the final analysis, all level IV case series. The majority was treated with single-stage revision with adjuvant IA antibiotic infusion (79.1%). The remaining PJIs were treated with stand-alone IA antibiotic infusion (12.2%), DAIR (debridement, antibiotics and implant retention) with adjuvant IA antibiotic infusion (5.7%) or two-stage revision with adjuvant IA antibiotic infusion (3.0%). Mean duration of IA antibiotic infusion was 19 days (range 3-50). An overall failure rate of approximately 11% was found. In total 117 complications occurred, 71 were non-catheter-related and 46 were catheter-related. The most common catheter-related complications were premature loss of the catheter (18/46) and elevated blood urea nitrogen (BUN) and creatinine levels (12/46). CONCLUSIONS Due to the lack of comparative studies the (added) benefit of IA antibiotic infusion in the treatment of PJI remains uncertain. Based on the current evidence, we would advise against using it as a stand-alone treatment. A prospective randomized controlled trial using a well-described infusion protocol is needed to see if the potential benefits justify the increased costs and potential complications of this treatment modality.
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Affiliation(s)
- S Bruyninckx
- Department of Orthopaedic Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - W J Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Herestraat 49-Box 805, 3000, Leuven, Belgium
| | - M Depypere
- Department of Laboratory Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - L Henckaerts
- Department of Microbiology, Immunology and Transplantation, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Laboratory for Clinical Infectious and Inflammatory Disorders, KU Leuven, Herestraat 49, Leuven, Belgium
| | - E van den Hout
- Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Laboratory for Clinical Infectious and Inflammatory Disorders, KU Leuven, Herestraat 49, Leuven, Belgium
| | - J Onsea
- Department of Trauma Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Herestraat 49-Box 805, 3000, Leuven, Belgium
| | - S Ghijselings
- Department of Orthopaedic Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - G F Vles
- Department of Orthopaedic Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
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Andries A, Deschrevel J, Maes K, De Beukelaer N, Corvelyn M, Staut L, De Houwer H, Costamagna D, Nijs S, Metsemakers WJ, Nijs E, Hens G, De Wachter E, Prinsen S, Desloovere K, Van Campenhout A, Gayan-Ramirez G. Histological analysis of the medial gastrocnemius muscle in young healthy children. Front Physiol 2024; 15:1336283. [PMID: 38651045 PMCID: PMC11034367 DOI: 10.3389/fphys.2024.1336283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 03/19/2024] [Indexed: 04/25/2024] Open
Abstract
Introduction: Histological data on muscle fiber size and proportion in (very) young typically developing (TD) children is not well documented and data on capillarization and satellite cell content are also lacking. Aims: This study investigated the microscopic properties of the medial gastrocnemius muscle in growing TD children, grouped according to age and gender to provide normal reference values in healthy children. Methods: Microbiopsies of the medial gastrocnemius (MG) muscle were collected in 46 TD boys and girls aged 2-10 years subdivided into 4 age groups (2-4, 4-6, 6-8 and 8-10 years). Sections were immunostained to assess fiber type cross-sectional area (fCSA) and proportion, the number of satellite cells (SC), capillary to fiber ratio (C/F), capillary density for type I and II fiber (CFD), capillary domain, capillary-to-fiber perimeter exchange index (CFPE) and heterogeneity index. fCSA was normalized to fibula length2 and the coefficient of variation (CV) was calculated to reflect fCSA intrasubject variability. Results: Absolute fCSA of all fibers increased with age (r = 0.72, p < 0.001) but more in boys (+112%, p < 0.05) than in girls (+48%, p > 0.05) Normalized fCSA, CV and fiber proportion did not differ between age groups and gender. C/F was strongly correlated with age in boys (r = 0.83, p < 0.001), and to a lesser extent in girls (r = 0.37, p = 0.115), while other capillary parameters as well as the number of SC remained stable with increasing age in boys and girls. Discussion: This study provides reference values of histological measures in MG according to age in normally growing boys and girls. These data may be used as a reference to determine disease impact and efficacy of therapeutic approach on the muscle.
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Affiliation(s)
- Anke Andries
- Laboratory of Respiratory Diseases and Thoracic Surgery, Department of Chronic Diseases and Metabolism, KU-Leuven, Leuven, Belgium
| | - Jorieke Deschrevel
- Laboratory of Respiratory Diseases and Thoracic Surgery, Department of Chronic Diseases and Metabolism, KU-Leuven, Leuven, Belgium
| | - Karen Maes
- Laboratory of Respiratory Diseases and Thoracic Surgery, Department of Chronic Diseases and Metabolism, KU-Leuven, Leuven, Belgium
| | - Nathalie De Beukelaer
- Neurorehabilitation Group, Department of Rehabilitation Sciences, KU-Leuven, Leuven, Belgium
| | - Marlies Corvelyn
- Stem Cell and Developmental Biology, Department of Development and Regeneration, KU-Leuven, Leuven, Belgium
| | - Lauraine Staut
- Neurorehabilitation Group, Department of Rehabilitation Sciences, KU-Leuven, Leuven, Belgium
| | - Hannah De Houwer
- Pediatric Orthopedics, Department of Development and Regeneration, KU-Leuven, Leuven, Belgium
| | - Domiziana Costamagna
- Neurorehabilitation Group, Department of Rehabilitation Sciences, KU-Leuven, Leuven, Belgium
- Stem Cell and Developmental Biology, Department of Development and Regeneration, KU-Leuven, Leuven, Belgium
- Exercise Physiology Research Group, Department of Movement Sciences, KU-Leuven, Leuven, Belgium
| | - Stefaan Nijs
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - Elga Nijs
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Greet Hens
- Department of Ear Nose Throat, University Hospitals Leuven, Leuven, Belgium
| | - Eva De Wachter
- Department of Orthopaedic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Sandra Prinsen
- Department of Orthopaedic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Kaat Desloovere
- Neurorehabilitation Group, Department of Rehabilitation Sciences, KU-Leuven, Leuven, Belgium
| | - Anja Van Campenhout
- Pediatric Orthopedics, Department of Development and Regeneration, KU-Leuven, Leuven, Belgium
| | - Ghislaine Gayan-Ramirez
- Laboratory of Respiratory Diseases and Thoracic Surgery, Department of Chronic Diseases and Metabolism, KU-Leuven, Leuven, Belgium
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Marais LC, Zalavras CG, Moriarty FT, Kühl R, Metsemakers WJ, Morgenstern M. The surgical management of fracture-related infection. Surgical strategy selection and the need for early surgical intervention. J Orthop 2024; 50:36-41. [PMID: 38162257 PMCID: PMC10755499 DOI: 10.1016/j.jor.2023.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/14/2023] [Indexed: 01/03/2024] Open
Abstract
The aim of this narrative review is to describe the various surgical management strategies employed in fracture-related infection (FRI), to explore how they are selected and discuss the rationale for early surgical intervention. Surgical treatment options in patients with FRI include debridement, antibiotics and implant retention (DAIR), revision (exchange) or removal. In selecting a treatment strategy, a variety of factors need to be considered, including the condition of the bone, soft tissues, host and causative microorganism. Irrespective of the selected treatment strategy, prompt surgical intervention should be considered in order to confirm the diagnosis of an FRI, to identify the causative organism, remove necrotic or non-viable tissue that can serve as a nidus for ongoing infection, ensure a healthy soft tissue envelope and to prevent the vicious cycle of infection associated with skeletal and/or implant instability. Ultimately, the objective is to prevent the establishment of a persistent infection. Urgent surgery may be indicated in case of active, progressive disease with systemic deterioration, local progression of infection, deterioration of soft tissues, or progressive fracture instability. In case of static disease, the patient should be monitored closely and surgery can be performed on an elective basis, allowing adequate time for optimisation of the host through risk factor modification, optimisation of the soft tissues and careful planning of the surgery.
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Affiliation(s)
- Leonard C. Marais
- Department of Orthopaedics, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Charalampos G. Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - Fintan T. Moriarty
- AO Research Institute Davos, Davos, Switzerland
- Center for Musculoskeletal Infections, Department of Orthopaedics and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Richard Kühl
- Center for Musculoskeletal Infections, Department of Orthopaedics and Trauma Surgery, University Hospital Basel, Basel, Switzerland
- Department of Infectious Diseases and Hospital Hygiene, University Hospital Basel, Switzerland
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Mario Morgenstern
- Center for Musculoskeletal Infections, Department of Orthopaedics and Trauma Surgery, University Hospital Basel, Basel, Switzerland
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Cools J, Ghijselings S, Ruythooren F, Jentjens S, Noppe N, Metsemakers WJ, Vles G. Advanced imaging shows extra-articular abscesses in two out of three adult patients with septic arthritis of the native hip joint. J Bone Jt Infect 2024; 9:27-35. [PMID: 38601001 PMCID: PMC11002917 DOI: 10.5194/jbji-9-27-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 12/07/2023] [Indexed: 04/12/2024] Open
Abstract
Background: Septic arthritis (SA) of the native adult hip is a rare orthopaedic emergency requiring prompt diagnosis and treatment. As clinical presentation and laboratory findings are frequently atypical, advanced imaging is often requested. This retrospective study aimed to investigate the prevalence and pattern of extra-articular infectious manifestations and their implications for pre-operative advanced imaging in patients with proven SA of the native hip joint. Methods: Out of 41 patients treated surgically for SA of the native hip during a 16-year period at our tertiary referral hospital, 25 received advanced imaging (computed tomography (CT), magnetic resonance imaging (MRI), or fluorodeoxyglucose positron emission tomography (FDG PET-CT)) prior to initial intervention. For each investigation, a specific set of variables was systematically interpreted, and the most suitable surgical approach was determined. The prognostic value was evaluated by comparing specific outcome measures and the extent of extra-articular involvement. Results: It was found that 32 % of patients had an abscess in one anatomical region, 32 % of patients had abscesses in multiple anatomical regions, and only 36 % of patients had no substantial abscess. Gluteal abscesses were especially common in patients with SA due to contiguous spread. Abscesses in the iliopsoas region were more common in patients with SA due to hematogenous seeding. A combination of several different surgical approaches was deemed necessary to adequately deal with the various presentations. No significant prognostic factors could be identified. Conclusion: We recommend performing advanced imaging in patients with suspected or proven septic arthritis of the native hip joint, as extra-articular abscesses are present in 64 % and might require varying anatomical approaches.
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Affiliation(s)
- Jordi Cools
- Department of Orthopaedic Surgery, University Hospitals Leuven – Gasthuisberg, Leuven, Belgium
- Institute for Orthopaedic Research and Training (IORT), Catholic University Leuven, Leuven, Belgium
| | - Stijn Ghijselings
- Department of Orthopaedic Surgery, University Hospitals Leuven – Gasthuisberg, Leuven, Belgium
- Institute for Orthopaedic Research and Training (IORT), Catholic University Leuven, Leuven, Belgium
| | - Fred Ruythooren
- Department of Orthopaedic Surgery, University Hospitals Leuven – Gasthuisberg, Leuven, Belgium
- Institute for Orthopaedic Research and Training (IORT), Catholic University Leuven, Leuven, Belgium
| | - Sander Jentjens
- Department of Nuclear Medicine, University Hospitals Leuven – Gasthuisberg, Leuven, Belgium
| | - Nathalie Noppe
- Department of Radiology, University Hospitals Leuven – Gasthuisberg, Leuven, Belgium
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven – Gasthuisberg, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Georges Vles
- Department of Orthopaedic Surgery, University Hospitals Leuven – Gasthuisberg, Leuven, Belgium
- Institute for Orthopaedic Research and Training (IORT), Catholic University Leuven, Leuven, Belgium
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Rodarte P, O'Marr J, Haonga B, Patrick D, Niknam K, Urva M, Cortez A, Metsemakers WJ, Shearer D, Morshed S. Diagnostic Performance of a telephone questionnaire for fracture-related infections (FRIs) in open tibia fracture patients in Tanzania. Injury 2024; 55:111179. [PMID: 37972489 DOI: 10.1016/j.injury.2023.111179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 10/26/2023] [Accepted: 10/31/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Fracture-related infections (FRIs) are a major cause of trauma-associated morbidity worldwide. In 2018, an expert group supported by the AO Foundation, European Bone and Joint Infection Society developed a consensus definition of FRI. Still, there is limited knowledge on the applicability of this definition in low- and middle-income countries (LMICs). Given the unique barriers that cause low follow-up rates for orthopaedic trauma patients in LMICs, this study aims to evaluate the diagnostic performance of a telephone questionnaire in identifying patients with FRIs after open tibia fracture fixation in Tanzania. MATERIALS AND METHODS Patients from a randomized controlled trial investigating the infection prevention benefit of locally applied gentamycin for open tibial fractures were included. Patients completed FRI based telephone questionnaires 7-10 days prior to scheduled follow-ups at 6 weeks, 3 months, 6 months, 9 months, and 1 year. The questionnaire included two "confirmatory" criteria questions for FRI (i.e., open wound and purulent drainage) and three "suggestive" criteria questions (i.e., wound drainage, fever, and warmth). Contingency tests were performed to identify the sensitivity and specificity between answers and adjudicated FRI diagnoses at the corresponding in-person follow-up. Data was analysed using STATA version 15.0 and MedCalc's online diagnostic test calculator. RESULTS There were a total of 234 complete questionnaires and 85 unique patients included. The sensitivity and specificity of having any positive answer in the questionnaire was highest at 6 months (100 % and 92.5 %, respectively). For all time-points pooled, sensitivity was 71.4 % and specificity was 93.0 %. Drainage had the highest sensitivity (71.4 %) while fever had the highest specificity (99.6 %). For confirmatory criteria, sensitivity was 14.3 % and specificity was 96.0 %. Contrastingly, the sensitivity for suggestive criteria was higher (71.4 %), with a similar specificity (93.8 %). CONCLUSION Our study indicates that telephone questionnaires have adequate diagnostic performance when assessing FRIs. The presence of drainage identified the majority of patients with FRI, and specificities were high across confirmatory and suggestive criteria. Our study is one of the first to evaluate telephone questionnaires as a diagnostic tool for FRIs in patients with open tibia fractures in a LMIC hospital and validates the FRI consensus definition criteria.
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Affiliation(s)
- Patricia Rodarte
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA, USA
| | - Jamieson O'Marr
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA, USA
| | - Billy Haonga
- Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
| | | | - Kian Niknam
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA, USA
| | - Mayur Urva
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA, USA
| | - Abigail Cortez
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA, USA
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - David Shearer
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA, USA
| | - Saam Morshed
- Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, CA, USA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA.
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6
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Marais LC, Hungerer S, Eckardt H, Zalavras C, Obremskey WT, Ramsden A, McNally MA, Morgenstern M, Metsemakers WJ. Key aspects of soft tissue management in fracture-related infection: recommendations from an international expert group. Arch Orthop Trauma Surg 2024; 144:259-268. [PMID: 37921993 PMCID: PMC10774153 DOI: 10.1007/s00402-023-05073-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 09/11/2023] [Indexed: 11/05/2023]
Abstract
A judicious, well-planned bone and soft tissue debridement remains one of the cornerstones of state-of-the-art treatment of fracture-related infection (FRI). Meticulous surgical excision of all non-viable tissue can, however, lead to the creation of large soft tissue defects. The management of these defects is complex and numerous factors need to be considered when selecting the most appropriate approach. This narrative review summarizes the current evidence with respect to soft tissue management in patients diagnosed with FRI. Specifically we discuss the optimal timing for tissue closure following debridement in cases of FRI, the need for negative microbiological culture results from the surgical site as a prerequisite for definitive wound closure, the optimal type of flap in case of large soft tissue defects caused by FRI and the role of negative pressure wound therapy (NPWT) in FRI. Finally, recommendations are made with regard to soft tissue management in FRI that should be useful for clinicians in daily clinical practice.Level of evidence Level V.
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Affiliation(s)
- Leonard C Marais
- Department of Orthopaedics, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Sven Hungerer
- Department of Joint Surgery and Arthroplasty, Trauma Center Murnau, Murnau Germany and Paracelsus Medical University (PMU) Salzburg, Salzburg, Austria
| | - Henrik Eckardt
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Charalampos Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - William T Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alex Ramsden
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Martin A McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Mario Morgenstern
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
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Uyttebroek S, Bessems L, Metsemakers WJ, Debaveye Y, Van Gerven L, Dupont L, Depypere M, Wagemans J, Lavigne R, Merabishvili M, Pirnay JP, Devolder D, Spriet I, Onsea J. Stability of magistral phage preparations before therapeutic application in patients with chronic rhinosinusitis, sepsis, pulmonary, and musculoskeletal infections. Microbiol Spectr 2023; 11:e0290723. [PMID: 37819122 PMCID: PMC10715222 DOI: 10.1128/spectrum.02907-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 08/30/2023] [Indexed: 10/13/2023] Open
Abstract
IMPORTANCE As antimicrobial resistance becomes more prevalent, the application of (bacterio)phage therapy as an alternative treatment for difficult-to-treat infections is (re)gaining popularity. Over the past decade, numerous promising case reports and series have been published demonstrating the therapeutic potential of phage therapy. However, important questions remain regarding the optimal treatment protocol and, unlike for medicinal products, there are currently no predefined quality standards for the stability of phage preparations. Phage titers can be influenced by several factors which could lead to reduced titers after preparation and storage and, ultimately, subtherapeutic applications. Determining the stability of different phages in different recipients according to the route of administration is therefore one of the first important steps in establishing a standardized protocol for phage therapy.
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Affiliation(s)
- Saartje Uyttebroek
- Department of Otorhinolaryngology, Head and Neck surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Neurosciences, Experimental Otorhinolaryngology, Rhinology Research, KU Leuven, Leuven, Belgium
| | - Laura Bessems
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Yves Debaveye
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Laura Van Gerven
- Department of Otorhinolaryngology, Head and Neck surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Neurosciences, Experimental Otorhinolaryngology, Rhinology Research, KU Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology Research Group, KU Leuven, Leuven, Belgium
| | - Lieven Dupont
- Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases and Metabolism, Respiratory Diseases and Thoracic Surgery, KU Leuven, Leuven, Belgium
| | - Melissa Depypere
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, Laboratory of Clinical Bacteriology and Mycology, KU Leuven, Leuven, Belgium
| | - Jeroen Wagemans
- Department of Biosystems, Laboratory of Gene Technology, KU Leuven, Leuven, Belgium
| | - Rob Lavigne
- Department of Biosystems, Laboratory of Gene Technology, KU Leuven, Leuven, Belgium
| | - Maya Merabishvili
- Laboratory for Molecular and Cellular Technology, Queen Astrid Military Hospital, Brussels, Belgium
| | - Jean-Paul Pirnay
- Laboratory for Molecular and Cellular Technology, Queen Astrid Military Hospital, Brussels, Belgium
| | - David Devolder
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Isabel Spriet
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, Leuven, Belgium
| | - Jolien Onsea
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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8
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Chen B, Benavente LP, Chittò M, Wychowaniec JK, Post V, D'Este M, Constant C, Zeiter S, Feng W, Moreno MG, Trampuz A, Wagemans J, Onsea J, Richards RG, Lavigne R, Moriarty TF, Metsemakers WJ. Alginate microbeads and hydrogels delivering meropenem and bacteriophages to treat Pseudomonas aeruginosa fracture-related infections. J Control Release 2023; 364:159-173. [PMID: 37866403 DOI: 10.1016/j.jconrel.2023.10.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/18/2023] [Accepted: 10/19/2023] [Indexed: 10/24/2023]
Abstract
Bacteriophage (phage) therapy has shown promise in treating fracture-related infection (FRI); however, questions remain regarding phage efficacy against biofilms, phage-antibiotic interaction, administration routes and dosing, and the development of phage resistance. The goal of this study was to develop a dual antibiotic-phage delivery system containing hydrogel and alginate microbeads loaded with a phage cocktail plus meropenem and evaluate efficacy against muti-drug resistant Pseudomonas aeruginosa. Two phages (FJK.R9-30 and MK.R3-15) displayed enhanced antibiotic activity against P. aeruginosa biofilms when tested in combination with meropenem. The antimicrobial activity of both antibiotic and phage was retained for eight days at 37 °C in dual phage and antibiotic loaded hydrogel with microbeads (PA-HM). In a mouse FRI model, phages were recovered from all tissues within all treatment groups receiving dual PA-HM. Moreover, animals that received the dual PA-HM either with or without systemic antibiotics had less incidence of phage resistance and less serum neutralization compared to phages in saline. The dual PA-HM could reduce bacterial load in soft tissue when combined with systemic antibiotics, although the infection was not eradicated. The use of alginate microbeads and injectable hydrogel for controlled release of phages and antibiotics, leads to the reduced development of phage resistance and lower exposure to the adaptive immune system, which highlights the translational potential of the dual PA-HM. However, further optimization of phage therapy and its delivery system is necessary to achieve higher bacterial killing activity in vivo in the future.
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Affiliation(s)
- Baixing Chen
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Leuven, Belgium; AO Research Institute Davos, Davos, Switzerland
| | - Luis Ponce Benavente
- Center for Musculoskeletal Surgery Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | | | | | | | | | | | | | - Wenli Feng
- AO Research Institute Davos, Davos, Switzerland
| | - Mercedes González Moreno
- Center for Musculoskeletal Surgery Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Andrej Trampuz
- Center for Musculoskeletal Surgery Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | | | - Jolien Onsea
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | | | - Rob Lavigne
- Laboratory of Gene Technology, KU Leuven, Leuven, Belgium
| | | | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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9
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Metsemakers WJ, Moriarty TF, Morgenstern M, Marais L, Onsea J, O'Toole RV, Depypere M, Obremskey WT, Verhofstad MHJ, McNally M, Morshed S, Wouthuyzen-Bakker M, Zalavras C. The global burden of fracture-related infection: can we do better? Lancet Infect Dis 2023:S1473-3099(23)00503-0. [PMID: 38042164 DOI: 10.1016/s1473-3099(23)00503-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 12/04/2023]
Abstract
Fracture-related infection is a major complication related to musculoskeletal injuries that not only has important clinical consequences, but also a substantial socioeconomic impact. Although fracture-related infection is one of the oldest disease entities known to mankind, it has only recently been defined and, therefore, its global burden is still largely unknown. In this Personal View, we describe the origin of the term fracture-related infection, present the available data on its global impact, and discuss important aspects regarding its prevention and management that could lead to improved outcomes in both high-resource and low-resource settings. We also highlight the need for health-care systems to be adequately compensated for the high cost of human resources (trained staff) and well-equipped facilities required to adequately care for these complex patients. Our aim is to increase awareness among clinicians and policy makers that fracture-related infection is a disease entity that deserves prioritisation in terms of research, with the goal to standardise treatment and improve patient outcomes on a global scale.
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Affiliation(s)
- Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Leuven, Belgium.
| | - T Fintan Moriarty
- AO Research Institute Davos, Davos, Switzerland; Center for Musculoskeletal Infections, Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Mario Morgenstern
- Center for Musculoskeletal Infections, Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Leonard Marais
- Department of Orthopaedics, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Jolien Onsea
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Melissa Depypere
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - William T Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael H J Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Martin McNally
- The Bone Infection Unit, Oxford University Hospitals, Oxford, UK
| | - Saam Morshed
- Department of Orthopaedic Surgery and Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Charalampos Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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10
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Van De Sijpe G, Hublou W, Declercq P, Metsemakers WJ, Sermon A, Casteels M, Foulon V, Quintens C, Spriet I. Bedside check of medication appropriateness (BED-CMA) as a risk-based tool for bedside clinical pharmacy services: A proof-of-concept study at the trauma surgery ward. Comput Struct Biotechnol J 2023; 22:58-65. [PMID: 38022766 PMCID: PMC10656193 DOI: 10.1016/j.csbj.2023.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 10/10/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023] Open
Abstract
Background Bedside clinical pharmacy prevents drug-related problems, but is not feasible in many countries due to limited resources. Hence, clinical rules using structural information in the electronic health record can help identifying potentially inappropriate prescriptions (PIPs). We aimed to develop and implement a risk-based clinical pharmacy service and evaluate its impact on prescribing at the trauma surgery ward. Methods The proportion of residual PIPs per day, i.e. the number of PIPs that persisted up to 24 h after pharmacist intervention divided by the number of PIPs at T0, was evaluated before and after implementation of the intervention in an interrupted time series analysis. The pre-intervention cohort received usual pharmacy services, i.e. a 0.3 FTE clinical pharmacist trainee. Fifteen clinical rules, targeting antimicrobial, anticoagulant and analgesic therapy were implemented in the post-intervention period. The pre-intervention period was compared to two post-intervention scenarios: A) clinical rule alerts reviewed by a 0.3 FTE clinical pharmacist trainee; and B) clinical rule alerts reviewed daily for approximately 1 h by a clinical pharmacist trainee. Results Pre-intervention, a median proportion of 67% (range 0%-100%) residual PIPs per day was observed. Scenario A showed an immediate relative reduction of 14% (p = 0.72) and scenario B a significant immediate relative reduction of 85% (p = 0.0015) in residual PIPs per day. In scenario A, recommendations were provided for 19% of clinical rule alerts, of which 67% was accepted by the surgeon within 24 h. In scenario B, recommendations were given for 56% of alerts, of which 84% was accepted. Conclusions Using clinical rules is an effective approach to organize bedside clinical pharmacy services and improves prescribing at the trauma surgery ward. Advanced training and daily follow-up of the clinical rules are two requirements to be considered.
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Affiliation(s)
- Greet Van De Sijpe
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Wencke Hublou
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Peter Declercq
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | | | - An Sermon
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Minne Casteels
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Veerle Foulon
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Charlotte Quintens
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Isabel Spriet
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
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11
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Ruythooren F, Ghijselings S, Cools J, Depypere M, De Munter P, Metsemakers WJ, Vles G. Should treatment decisions in septic arthritis of the native hip joint be based on the route of infection? J Bone Jt Infect 2023; 8:209-218. [PMID: 38039332 PMCID: PMC10655073 DOI: 10.5194/jbji-8-209-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 08/21/2023] [Indexed: 12/03/2023] Open
Abstract
Background: Surgical management of septic arthritis (SA) of the hip aims at treating the infection by either preserving, resecting or replacing the joint. In some cases, joint preservation should be attempted, whereas other cases would benefit from immediate joint resection or replacement. Prognostic factors have been proposed to guide decision-making. We hypothesized that most of these factors can be simplified to three subgroups based on the route of infection: contiguous spreading, direct inoculation or hematogenous seeding. Methods: A total of 41 patients have been treated surgically for SA of the native hip at our tertiary hospital during the last 16 years. Medical records were studied, and various patient and disease characteristics were collated. Results: Significant differences between (1) level of fitness, (2) condition of the hip joint, (3) micro-organisms and (4) chance of femoral head preservation were found for patients with SA of the native hip resulting from the three aforementioned subgroups. Femoral head resection was necessary at one point in 85 % of patients. Patients with hematogenous infections of undamaged hips had a reasonable chance (53 %) of avoiding joint resection or replacement. Hip arthroplasty was performed on 46.3 % of patients, with an infection rate of 10.5 %. Conclusion: Patients with SA of the native hip resulting from contiguous spreading, hematogenous seeding or direct inoculation differ significantly and should be considered distinct clinical entities. Route of infection is directly related to the chance of femoral head preservation and should, therefore, guide decision-making. Only patients with hematogenous infection to a previously healthy hip had the possibility of femoral head preservation.
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Affiliation(s)
- Fred Ruythooren
- Department of Orthopaedic Surgery, University Hospitals Leuven - Gasthuisberg, Leuven, Belgium
- Institute for Orthopaedic Research and Training (IORT), Catholic University Leuven, Leuven, Belgium
| | - Stijn Ghijselings
- Department of Orthopaedic Surgery, University Hospitals Leuven - Gasthuisberg, Leuven, Belgium
- Institute for Orthopaedic Research and Training (IORT), Catholic University Leuven, Leuven, Belgium
| | - Jordi Cools
- Department of Orthopaedic Surgery, University Hospitals Leuven - Gasthuisberg, Leuven, Belgium
- Institute for Orthopaedic Research and Training (IORT), Catholic University Leuven, Leuven, Belgium
| | - Melissa Depypere
- Department of Laboratory Medicine, University Hospitals Leuven - Gasthuisberg, Leuven, Belgium
| | - Paul De Munter
- Department of General Internal Medicine, University Hospitals Leuven - Gasthuisberg, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, Laboratory for Clinical Infectious and Inflammatory Disorders, KU Leuven, Leuven, Belgium
| | - Willem-Jan Metsemakers
- Department of Traumatology, University Hospitals Leuven - Gasthuisberg, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - George Vles
- Department of Orthopaedic Surgery, University Hospitals Leuven - Gasthuisberg, Leuven, Belgium
- Institute for Orthopaedic Research and Training (IORT), Catholic University Leuven, Leuven, Belgium
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12
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Sliepen J, Hoekstra H, Onsea J, Bessems L, Depypere M, Noppe N, Herteleer M, Sermon A, Nijs S, Vranckx JJ, Metsemakers WJ. Treatment and outcome of fracture-related infection of the clavicle. Injury 2023; 54:110910. [PMID: 37421837 DOI: 10.1016/j.injury.2023.110910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/16/2023] [Accepted: 06/18/2023] [Indexed: 07/10/2023]
Abstract
INTRODUCTION The number of operatively treated clavicle fractures has increased over the past decades. Consequently, this has led to an increase in secondary procedures required to treat complications such as fracture-related infection (FRI). The primary objective of this study was to assess the clinical and functional outcome of patients treated for FRI of the clavicle. The secondary objectives were to evaluate the healthcare costs and propose a standardized protocol for the surgical management of this complication. METHODS All patients with a clavicle fracture who underwent open reduction and internal fixation (ORIF) between 1 January 2015 and 1 March 2022 were retrospectively evaluated. This study included patients with an FRI who were diagnosed and treated according to the recommendations of a multidisciplinary team at the University Hospitals Leuven, Belgium. RESULTS We evaluated 626 patients with 630 clavicle fractures who underwent ORIF. In total, 28 patients were diagnosed with an FRI. Of these, eight (29%) underwent definitive implant removal, five (18%) underwent debridement, antimicrobial treatment and implant retention, and fourteen patients (50%) had their implant exchanged in either a single-stage procedure, a two-stage procedure or after multiple revisions. One patient (3.6%) underwent resection of the clavicle. Twelve patients (43%) underwent autologous bone grafting (tricortical iliac crest bone graft (n = 6), free vascularized fibular graft (n = 5), cancellous bone graft (n = 1)) to reconstruct the bone defect. The median follow-up was 32.3 (P25-P75: 23.9-51.1) months. Two patients (7.1%) experienced a recurrence of infection. The functional outcome was satisfactory, with 26 out of 28 patients (93%) having full range of motion. The median healthcare cost was € 11.506 (P25-P75: € 7.953-23.798) per patient. CONCLUSION FRI is a serious complication that can occur after the surgical treatment of clavicle fractures. In our opinion, when treated adequately using a multidisciplinary patient-specific approach, the outcome of patients with an FRI of the clavicle is good. The median healthcare costs of these patients are up to 3.5 times higher compared to non-infected operatively treated clavicle fractures. Although not studied individually, we consider factors such as the size of the bone defect, condition of the soft tissue, and patient demand important when it comes to guiding our surgical decision making in cases of osseous defects.
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Affiliation(s)
- Jonathan Sliepen
- University Medical Center Groningen, Department of Trauma Surgery, University of Groningen, 9713 GZ Groningen, The Netherlands; University Hospitals Leuven, Department of Trauma Surgery, 3000 Leuven, Belgium
| | - Harm Hoekstra
- University Hospitals Leuven, Department of Trauma Surgery, 3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, 3000 Leuven, Belgium
| | - Jolien Onsea
- University Hospitals Leuven, Department of Trauma Surgery, 3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, 3000 Leuven, Belgium
| | - Laura Bessems
- University Hospitals Leuven, Department of Trauma Surgery, 3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, 3000 Leuven, Belgium
| | - Melissa Depypere
- University Hospitals Leuven, Department of Laboratory Medicine, 3000 Leuven, Belgium
| | - Nathalie Noppe
- University Hospitals Leuven, Department of Radiology, 3000 Leuven, Belgium
| | - Michiel Herteleer
- University Hospitals Leuven, Department of Trauma Surgery, 3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, 3000 Leuven, Belgium
| | - An Sermon
- University Hospitals Leuven, Department of Trauma Surgery, 3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, 3000 Leuven, Belgium
| | - Stefaan Nijs
- University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Jan J Vranckx
- University Hospitals Leuven, Department of Plastic and Reconstructive Surgery, 3000 Leuven, Belgium
| | - Willem-Jan Metsemakers
- University Hospitals Leuven, Department of Trauma Surgery, 3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, 3000 Leuven, Belgium.
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13
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Bakuradze N, Merabishvili M, Kusradze I, Ceyssens PJ, Onsea J, Metsemakers WJ, Grdzelishvili N, Natroshvili G, Tatrishvili T, Lazvliashvili D, Mitskevich N, Pirnay JP, Chanishvili N. Characterization of a Bacteriophage GEC_vB_Bfr_UZM3 Active against Bacteroides fragilis. Viruses 2023; 15:v15051042. [PMID: 37243129 DOI: 10.3390/v15051042] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/15/2023] [Accepted: 04/15/2023] [Indexed: 05/28/2023] Open
Abstract
Bacteroides fragilis is a commensal gut bacterium that is associated with a number of blood and tissue infections. It has not yet been recognized as one of the drug-resistant human pathogens, but cases of the refractory infections, caused by strains that are not susceptible to the common antibiotic regimes established for B. fragilis, have been more frequently reported. Bacteriophages (phages) were found to be a successful antibacterial alternative to antibiotic therapy in many cases of multidrug-resistant (MDR) bacterial infections. We have characterized the bacteriophage GEC_vB_Bfr_UZM3 (UZM3), which was used for the treatment of a patient with a chronic osteomyelitis caused by a B. fragilis mixed infection. Studied biological and morphological properties of UZM3 showed that it seems to represent a strictly lytic phage belonging to a siphovirus morphotype. It is characterized by high stability at body temperature and in pH environments for about 6 h. Whole genome sequencing analysis of the phage UZM3 showed that it does not harbor any known virulence genes and can be considered as a potential therapeutic phage to be used against B. fragilis infections.
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Affiliation(s)
- Nata Bakuradze
- Laboratory of Microbial Biotechnology, Eliava Institute of Bacteriophages, Microbiology and Virology, Tbilisi 0160, Georgia
- Department of Biology, Faculty of Exact and Natural Sciences, Javakhishvili Tbilisi State University, Tbilisi 0179, Georgia
- AIETI Medical School, Davit Tvildiani Medical University, Tbilisi 0159, Georgia
| | - Maia Merabishvili
- Laboratory for Molecular and Cellular Technology, Queen Astrid Military Hospital, 1120 Brussels, Belgium
| | - Ia Kusradze
- Laboratory of General Microbiology, Eliava Institute of Bacteriophages, Microbiology and Virology, Tbilisi 0160, Georgia
- Faculty of Medicine, European University, Tbilisi 0141, Georgia
| | | | - Jolien Onsea
- Department of Trauma Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
| | - Nino Grdzelishvili
- Laboratory of Microbial Biotechnology, Eliava Institute of Bacteriophages, Microbiology and Virology, Tbilisi 0160, Georgia
- Faculty of Natural Science and Medicine, Ilia State University, Tbilisi 0162, Georgia
| | - Guliko Natroshvili
- Laboratory of Microbial Biotechnology, Eliava Institute of Bacteriophages, Microbiology and Virology, Tbilisi 0160, Georgia
| | - Tamar Tatrishvili
- Laboratory of Microbial Biotechnology, Eliava Institute of Bacteriophages, Microbiology and Virology, Tbilisi 0160, Georgia
- Faculty of Natural Science and Medicine, Ilia State University, Tbilisi 0162, Georgia
| | - Davit Lazvliashvili
- Laboratory of Microbial Biotechnology, Eliava Institute of Bacteriophages, Microbiology and Virology, Tbilisi 0160, Georgia
- Faculty of Natural Science and Medicine, Ilia State University, Tbilisi 0162, Georgia
| | - Nunu Mitskevich
- Department of Biology, Faculty of Exact and Natural Sciences, Javakhishvili Tbilisi State University, Tbilisi 0179, Georgia
| | - Jean-Paul Pirnay
- Laboratory for Molecular and Cellular Technology, Queen Astrid Military Hospital, 1120 Brussels, Belgium
| | - Nina Chanishvili
- Laboratory of Microbial Biotechnology, Eliava Institute of Bacteriophages, Microbiology and Virology, Tbilisi 0160, Georgia
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14
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Onsea J, Van Lieshout EMM, Zalavras C, Sliepen J, Depypere M, Noppe N, Ferguson J, Verhofstad MHJ, Govaert GAM, IJpma FFA, McNally MA, Metsemakers WJ. Corrigendum to: Validation of the diagnostic criteria of the consensus definition of fracture-related infectionInjury (2022);53, pages 1867-1879. Injury 2023:S0020-1383(23)00273-5. [PMID: 36959020 DOI: 10.1016/j.injury.2023.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Affiliation(s)
- Jolien Onsea
- University Hospitals Leuven, Department of Trauma Surgery, Leuven, Belgium.; KU Leuven - University of Leuven, Department of Development and Regeneration, Leuven, Belgium
| | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Charalampos Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - Jonathan Sliepen
- Department of Trauma Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Melissa Depypere
- University Hospitals Leuven, Department of laboratory medicine, Leuven, Belgium
| | - Nathalie Noppe
- University Hospitals Leuven, Department of radiology, Leuven, Belgium
| | - Jamie Ferguson
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Michael H J Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Geertje A M Govaert
- Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank F A IJpma
- Department of Trauma Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Martin A McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Willem-Jan Metsemakers
- University Hospitals Leuven, Department of Trauma Surgery, Leuven, Belgium.; KU Leuven - University of Leuven, Department of Development and Regeneration, Leuven, Belgium..
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15
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Mufty H, Van Den Eynde J, Meuris B, Metsemakers WJ, Van Wijngaerden E, Vandendriessche T, Steenackers HP, Fourneau I. Erratum to "Preclinical In Vitro Models of Vascular Graft Coating in the Prevention of Vascular Graft Infection: A Systematic Review" [Eur J Vasc Endovasc Surg 63 (2022) 119-137]. Eur J Vasc Endovasc Surg 2023; 65:615. [PMID: 36805090 DOI: 10.1016/j.ejvs.2023.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Affiliation(s)
- Hozan Mufty
- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Research Unit of Vascular Surgery, KU Leuven, Leuven, Belgium.
| | - Jef Van Den Eynde
- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Research Unit of Vascular Surgery, KU Leuven, Leuven, Belgium
| | - Bart Meuris
- Department of Cardiovascular Sciences, Research Unit of Vascular Surgery, KU Leuven, Leuven, Belgium; Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - Eric Van Wijngaerden
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | | | - Hans P Steenackers
- Department of Microbial and Molecular Systems, Centre of Microbial and Plant Genetics, KU Leuven, Leuven, Belgium
| | - Inge Fourneau
- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Research Unit of Vascular Surgery, KU Leuven, Leuven, Belgium
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16
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Metsemakers WJ, Onsea J, Moriarty TF, Pruidze N, Nadareishvili L, Dadiani M, Kutateladze M. Bacteriophage therapy for human musculoskeletal and skin/soft tissue infections. Clin Microbiol Infect 2023:S1198-743X(23)00033-2. [PMID: 36669559 DOI: 10.1016/j.cmi.2023.01.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 12/19/2022] [Accepted: 01/09/2023] [Indexed: 01/18/2023]
Abstract
BACKGROUND Bacteriophage therapy has a long history in the treatment of musculoskeletal and skin/soft tissue infections, particularly in the former Soviet Union. Due to the global rise in antimicrobial resistance, phage application has experienced a resurgence of interest and expanded to many countries. OBJECTIVES This narrative review aims to provide clinical microbiologists, infectious disease specialists and surgeons a brief history of bacteriophage therapy for human musculoskeletal and soft tissue infections, as well as data on current practices and ongoing clinical studies. SOURCES A search of PubMed and Clinicaltrials.gov was performed to identify relevant studies. Search terms were 'bacteriophage therapy', 'musculoskeletal infection' and 'soft tissue infection'. The bibliography of all retrieved articles was checked for additional relevant references. CONTENT Past and current data on the use of bacteriophage therapy for human musculoskeletal, skin and soft tissue infections are evaluated. Moreover, we present the clinical trials registered in public databases. Based on current clinical experience and data, several scenarios of bacteriophage application for human therapy are examined. Finally, we discuss legislative hurdles in the regulatory approval process and present future perspectives for bacteriophage therapy. IMPLICATIONS Antimicrobial resistance is one of the most important global public health challenges. Several different alternatives to conventional antibiotics are under development; bacteriophage therapy is one of them. Currently, therapeutic use of phages is restrained by regulatory hurdles and largely limited to sporadic authorization in compassionate use or under temporary approval as new drugs in Europe and the US. Although bacteriophage therapy seems to be safe and clinical results of phage treatment are promising, future data from high-quality (randomized controlled) trials could provide a better understanding of the reasonable minimal criteria required for expansion of bacteriophage therapy.
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Affiliation(s)
- Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Jolien Onsea
- Department of Trauma Surgery, University Hospitals, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | | | | | | | | | - Mzia Kutateladze
- George Eliava Institute of Bacteriophages, Microbiology and Virology, Tbilisi, Georgia.
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17
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Vanvelk N, Van Lieshout E, Onsea J, Sliepen J, Govaert G, IJpma F, Depypere M, Ferguson J, McNally M, Obremskey W, Zalavras C, Verhofstad M, Metsemakers WJ. Diagnosis of fracture-related infection in patients without clinical confirmatory criteria: an international retrospective cohort study. J Bone Jt Infect 2023; 8:133-142. [PMID: 37123499 PMCID: PMC10134751 DOI: 10.5194/jbji-8-133-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 03/27/2023] [Indexed: 05/02/2023] Open
Abstract
Background: fracture-related infection (FRI) remains a serious complication in orthopedic trauma. To standardize daily clinical practice, a consensus definition was established, based on confirmatory and suggestive criteria. In the presence of clinical confirmatory criteria, the diagnosis of an FRI is evident, and treatment can be started. However, if these criteria are absent, the decision to surgically collect deep tissue cultures can only be based on suggestive criteria. The primary study aim was to characterize the subpopulation of FRI patients presenting without clinical confirmatory criteria (fistula, sinus, wound breakdown, purulent wound drainage or presence of pus during surgery). The secondary aims were to describe the prevalence of the diagnostic criteria for FRI and present the microbiological characteristics, both for the entire FRI population. Methods: a multicenter, retrospective cohort study was performed, reporting the demographic, clinical and microbiological characteristics of 609 patients (with 613 fractures) who were treated for FRI based on the recommendations of a multidisciplinary team. Patients were divided in three groups, including the total population and two subgroups of patients presenting with or without clinical confirmatory criteria. Results: clinical and microbiological confirmatory criteria were present in 77 % and 87 % of the included fractures, respectively. Of patients, 23 % presented without clinical confirmatory criteria, and they mostly displayed one (31 %) or two (23 %) suggestive clinical criteria (redness, swelling, warmth, pain, fever, new-onset joint effusion, persisting/increasing/new-onset wound drainage). The prevalence of any suggestive clinical, radiological or laboratory criteria in this subgroup was 85 %, 55 % and 97 %, respectively. Most infections were monomicrobial (64 %) and caused by Staphylococcus aureus. Conclusion: clinical confirmatory criteria were absent in 23 % of the FRIs. In these cases, the decision to operatively collect deep tissue cultures was based on clinical, radiological and laboratory suggestive criteria. The combined use of these criteria should guide physicians in the management pathway of FRI. Further research is needed to provide guidelines on the decision to proceed with surgery when only these suggestive criteria are present.
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Affiliation(s)
- Niels Vanvelk
- Trauma Research Unit, Department of Surgery, Erasmus MC, University
Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Esther M. M. Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University
Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Jolien Onsea
- Department of Trauma Surgery, University Hospitals Leuven, Leuven,
Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Jonathan Sliepen
- Department of Trauma Surgery, University Medical Centre Groningen,
Groningen, the Netherlands
| | - Geertje Govaert
- Department of Trauma Surgery, University Medical Centre Utrecht,
Utrecht, the Netherlands
| | - Frank F. A. IJpma
- Department of Trauma Surgery, University Medical Centre Groningen,
Groningen, the Netherlands
| | - Melissa Depypere
- Department of laboratory medicine, University Hospitals Leuven,
Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, Laboratory
of Clinical Bacteriology and Mycology, KU Leuven, Leuven, Belgium
| | - Jamie Ferguson
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford
University Hospitals, Oxford, UK
| | - Martin McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford
University Hospitals, Oxford, UK
| | - William T. Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt
University Medical Center, Nashville, Tennessee, USA
| | - Charalampos Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine,
University of Southern California, Los Angeles, USA
| | - Michael H. J. Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University
Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven,
Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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18
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Sweere V, Sliepen J, Haidari S, Depypere M, Mertens M, IJpma F, Metsemakers WJ, Govaert G. Use of negative pressure wound therapy in patients with fracture-related infection more than doubles the risk of recurrence. Injury 2022; 53:3938-3944. [PMID: 36424686 DOI: 10.1016/j.injury.2022.10.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 07/11/2022] [Accepted: 10/16/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE Fracture-related infection (FRI) is one of the most serious complications in orthopedic trauma surgery. Despite its widespread use, the role of Negative Pressure Wound Therapy (NPWT) remains controversial in the management pathway of FRI. The aim of this study was to assess the relationship between the application of NPWT and its duration and recurrence of infection in operatively treated FRI patients. PATIENTS AND METHODS This is a retrospective cohort study based on the FRI database of three level 1 Trauma Centres. Included patients had to be at least 16 years of age and surgically treated for FRI between January 1st 2015 and September 1st 2020. Patients were subdivided in either the NPWT group, when NPWT was applied as part of the FRI treatment, or in the control group, when no NPWT had been applied. To limit confounding, patients were excluded if they (also) underwent NPWT prior to the diagnosis of FRI. The relation between the duration of NPWT during FRI treatment and the recurrence rate of infection was analyzed using a multivariable logistic regression model. RESULTS A total of 263 patients were included, 99 in the NPWT group and 164 in the control group. The median duration of NPWT was 18.0 (IQR 15.8) days. In the NPWT group, 28 patients (28.3%) developed a recurrent FRI. In the control group, 19 patients (11.6%) had a recurrent FRI (p = 0.001, 95% CI [0.174 - 0.635]). In the NPWT group there were no significant differences in baseline characteristics between the recurrence and non-recurrence group. The duration of NPWT was associated with a higher risk of recurrence of infection (p = 0.013, OR 1.036, 95% CI [1.008 - 1.066]). CONCLUSION Delayed wound closure with the application of NPWT increased the risk of recurrence of infection in patients with soft tissue defects after FRI treatment. Therefore, it is advised to consider NPWT only as a short-term (e.g. few days) necessity to bridge the period until definitive wound closure can be established.
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Affiliation(s)
- Vera Sweere
- Department of Trauma Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jonathan Sliepen
- Department of Trauma Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Susan Haidari
- Department of Trauma Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Melissa Depypere
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Maarten Mertens
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Frank IJpma
- Department of Trauma Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; KU Leuven - University of Leuven, Department of Development and Regeneration, Leuven, Belgium
| | - Geertje Govaert
- Department of Trauma Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands.
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19
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Moriarty TF, Metsemakers WJ, Morgenstern M, Hofstee MI, Vallejo Diaz A, Cassat JE, Wildemann B, Depypere M, Schwarz EM, Richards RG. Fracture-related infection. Nat Rev Dis Primers 2022; 8:67. [PMID: 36266296 DOI: 10.1038/s41572-022-00396-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/13/2022] [Indexed: 11/09/2022]
Abstract
Musculoskeletal trauma leading to broken and damaged bones and soft tissues can be a life-threating event. Modern orthopaedic trauma surgery, combined with innovation in medical devices, allows many severe injuries to be rapidly repaired and to eventually heal. Unfortunately, one of the persisting complications is fracture-related infection (FRI). In these cases, pathogenic bacteria enter the wound and divert the host responses from a bone-healing course to an inflammatory and antibacterial course that can prevent the bone from healing. FRI can lead to permanent disability, or long courses of therapy lasting from months to years. In the past 5 years, international consensus on a definition of these infections has focused greater attention on FRI, and new guidelines are available for prevention, diagnosis and treatment. Further improvements in understanding the role of perioperative antibiotic prophylaxis and the optimal treatment approach would be transformative for the field. Basic science and engineering innovations will be required to reduce infection rates, with interventions such as more efficient delivery of antibiotics, new antimicrobials, and optimizing host defences among the most likely to improve the care of patients with FRI.
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Affiliation(s)
- T Fintan Moriarty
- AO Research Institute Davos, Davos, Switzerland.,Center for Musculoskeletal Infections, Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Mario Morgenstern
- Center for Musculoskeletal Infections, Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | | | - Alejandro Vallejo Diaz
- Department of Orthopedics and Traumatology, Hospital Alma Mater de Antioquia, Medellín, Colombia.,Department of Orthopedics and Traumatology, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - James E Cassat
- Department of Paediatrics, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Biomedical Engineering, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Britt Wildemann
- Experimental Trauma Surgery, Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Melissa Depypere
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium.,Department of Microbiology, Immunology and Transplantation, Laboratory of Clinical Bacteriology and Mycology, KU Leuven, Leuven, Belgium
| | - Edward M Schwarz
- Center for Musculoskeletal Research, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - R Geoff Richards
- AO Research Institute Davos, Davos, Switzerland. .,School of Veterinary Science, Aberystwyth University, Aberystwyth, UK.
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20
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Depypere M, Sliepen J, Onsea J, Debaveye Y, Govaert GAM, IJpma FFA, Zimmerli W, Metsemakers WJ. The Microbiological Etiology of Fracture-Related Infection. Front Cell Infect Microbiol 2022; 12:934485. [PMID: 35873162 PMCID: PMC9300981 DOI: 10.3389/fcimb.2022.934485] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 06/14/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose Fracture-related infection (FRI) is an important complication related to orthopaedic trauma. Although the scientific interest with respect to the diagnosis and treatment of FRI is increasing, data on the microbiological epidemiology remains limited. Therefore, the primary aim of this study was to evaluate the microbiological epidemiology related to FRI, including the association with clinical symptoms and antimicrobial susceptibility data. The secondary aim was to analyze whether there was a relationship between the time to onset of infection and the microbiological etiology of FRI. Methods FRI patients treated at the University Hospitals of Leuven, Belgium, between January 1st 2015 and November 24th 2019 were evaluated retrospectively. The microbiological etiology and antimicrobial susceptibility data were analyzed. Patients were classified as having an early (<2 weeks after implantation), delayed (2-10 weeks) or late-onset (> 10 weeks) FRI. Results One hundred ninety-one patients with 194 FRIs, most frequently involving the tibia (23.7%) and femur (18.6%), were included. Staphylococcus aureus was the most frequently isolated pathogen, regardless of time to onset (n=61; 31.4%), followed by S. epidermidis (n=50; 25.8%) and non-epidermidis coagulase-negative staphylococci (n=35; 18.0%). Polymicrobial infections (n=49; 25.3%), mainly involving Gram negative bacilli (GNB) (n=32; 65.3%), were less common than monomicrobial infections (n=138; 71.1%). Virulent pathogens in monomicrobial FRIs were more likely to cause pus or purulent discharge (n=45;54.9%; p=0.002) and fistulas (n=21;25.6%; p=0.030). Susceptibility to piperacillin/tazobactam for GNB was 75.9%. Vancomycin covered 100% of Gram positive cocci. Conclusion This study revealed that in early FRIs, polymicrobial infections and infections including Enterobacterales and enterococcal species were more frequent. A time-based FRI classification is not meaningful to estimate the microbiological epidemiology and cannot be used to guide empiric antibiotic therapy. Large multicenter prospective studies are necessary to gain more insight into the added value of (broad) empirical antibiotic therapy.
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Affiliation(s)
- Melissa Depypere
- Department of laboratory medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, Laboratory of Clinical Bacteriology and Mycology, KU Leuven, Leuven, Belgium
| | - Jonathan Sliepen
- Department of Trauma Surgery, University Medical Center Groningen, Groningen, Netherlands
| | - Jolien Onsea
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven - University of Leuven, Leuven, Belgium
| | - Yves Debaveye
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Geertje A. M. Govaert
- Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Utrecht, Netherlands
| | - Frank F. A. IJpma
- Department of Trauma Surgery, University Medical Center Groningen, Groningen, Netherlands
| | - Werner Zimmerli
- Basel University Medical Clinic, Kantonsspital Baselland, Liestal, Switzerland
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven - University of Leuven, Leuven, Belgium
- *Correspondence: Willem-Jan Metsemakers,
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21
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Onsea J, Van Lieshout EMM, Zalavras C, Sliepen J, Depypere M, Noppe N, Ferguson J, Verhofstad MHJ, Govaert GAM, IJpma FFA, McNally MA, Metsemakers WJ. Validation of the diagnostic criteria of the consensus definition of fracture-related infection. Injury 2022; 53:1867-1879. [PMID: 35331479 DOI: 10.1016/j.injury.2022.03.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND The recently developed fracture-related infection (FRI) consensus definition, which is based on specific diagnostic criteria, has not been fully validated in clinical studies. We aimed to determine the diagnostic performance of the criteria of the FRI consensus definition and evaluated the effect of the combination of certain suggestive and confirmatory criteria on the diagnostic performance. METHODS A multicenter, multi-national, retrospective cohort study was performed. Patients were subdivided into an FRI or a control group, according to the treatment they received and the recommendations from a multidisciplinary team ('intention to treat'). Exclusion criteria were patients with an FRI diagnosed outside the study period, patients younger than 18 years of age, patients with pathological fractures or patients with fractures of the skull, cervical, thoracic and lumbar spine. Minimum follow up for all patients was 18 months. RESULTS Overall, 637 patients underwent revision surgery for suspicion of FRI. Of these, 480 patients were diagnosed with FRI, treated accordingly, and included in the FRI group. The other 157 patients were included in the control group. The presence of at least one confirmatory sign was associated with a sensitivity of 97.5%, a specificity of 100% and a high discriminatory value (AUROC 0.99, p < 0.001). The presence of a clinical confirmatory criterion or, if not present, at least one positive culture was associated with the highest diagnostic performance (sensitivity: 98.6%, specificity: 100%, AUROC: 0.99 (p < 0.001)). In the subgroup of patients without clinical confirmatory signs at presentation, specificities of at least 95% were found for the clinical suggestive signs of fever, wound drainage, local warmth and redness. CONCLUSIONS The presence of at least one confirmatory criterion identifies the vast majority of patients with an FRI and was associated with an excellent diagnostic discriminatory value. Therefore, our study validates the confirmatory criteria of the FRI consensus definition. Infection is highly likely in case of the presence of a single positive culture with a virulent pathogen. When certain clinical suggestive signs (e.g., wound drainage) are observed (individually or in combination and even without a confirmatory criterion), it is more likely than not, that an infection is present.
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Affiliation(s)
- Jolien Onsea
- University Hospitals Leuven, Department of Trauma Surgery, Leuven, Belgium; KU Leuven - University of Leuven, Department of Development and Regeneration, Leuven, Belgium
| | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Charalampos Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - Jonathan Sliepen
- Department of Trauma Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Melissa Depypere
- University Hospitals Leuven, Department of laboratory medicine, Leuven, Belgium
| | - Nathalie Noppe
- University Hospitals Leuven, Department of radiology, Leuven, Belgium
| | - Jamie Ferguson
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Michael H J Verhofstad
- Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Geertje A M Govaert
- Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank F A IJpma
- Department of Trauma Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Martin A McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Willem-Jan Metsemakers
- University Hospitals Leuven, Department of Trauma Surgery, Leuven, Belgium; KU Leuven - University of Leuven, Department of Development and Regeneration, Leuven, Belgium.
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22
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Declercq P, Zalavras C, Mertens B, Van der Linden L, Nijs S, Spriet I, Metsemakers WJ. Perioperative antibiotic prophylaxis in long bone open fractures: the need for randomized controlled trials. Arch Orthop Trauma Surg 2022; 142:1063-1064. [PMID: 33512582 DOI: 10.1007/s00402-021-03796-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 01/12/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Peter Declercq
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, University of Leuven, Leuven, Belgium
| | - Charalampos Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - Beatrijs Mertens
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Lorenz Van der Linden
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, University of Leuven, Leuven, Belgium
| | - Stefaan Nijs
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
| | - Isabel Spriet
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, University of Leuven, Leuven, Belgium
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.
- Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium.
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23
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Declercq P, Zalavras C, Mertens B, Van der Linden L, Nijs S, Spriet I, Metsemakers WJ. Correction to: Perioperative antibiotic prophylaxis in long bone open fractures: the need for randomized controlled trials. Arch Orthop Trauma Surg 2022; 142:1065. [PMID: 33682024 DOI: 10.1007/s00402-021-03847-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Peter Declercq
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, University of Leuven, Leuven, Belgium
| | - Charalampos Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - Beatrijs Mertens
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Lorenz Van der Linden
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, University of Leuven, Leuven, Belgium
| | - Stefaan Nijs
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
| | - Isabel Spriet
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, University of Leuven, Leuven, Belgium
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium. .,Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium.
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24
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Boeckxstaens A, Hoekstra H, Depypere M, Nevens T, Nijs S, Vranckx JJ, Metsemakers WJ. Fracture-related infection of the patella: Treatment options and outcome. Injury 2022; 53:1880-1886. [PMID: 35414406 DOI: 10.1016/j.injury.2022.03.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/24/2022] [Accepted: 03/28/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Fracture-related infection (FRI) after the operative management of patella fractures is a serious complication that can result in prolonged hospitalization, multiple revision procedures and permanent functional impairment. Till today, treatment modalities and outcome of FRI of the patella are not well described. Therefore, the main objective of this retrospective cohort study was to evaluate treatment options, functional outcome and healthcare costs related to FRI of the patella. METHODS This study evaluated 111 consecutive patients that were surgically treated for patella fractures, at the department of trauma surgery of the University Hospitals Leuven (Belgium), between January 2015 and April 2020. Patients were excluded if they (1) were younger than 18 years at the time of injury or (2) died during follow up. The minimal follow-up for all patients was 18 months. RESULTS During the 5-year study period, 107 patients with 108 patella fractures were included. A total of 10 patients were diagnosed with an FRI (9.3%). Four of these were treated with a DAIR approach and three patients underwent implant removal or exchange. Finally, three patients were treated with total patellectomy. Out of the 10 patients, two were diagnosed with a recurrence of infection. Overall, we observed substantial lower scores for all Knee Injury and Osteoarthritis Outcome Score subscales in the FRI group, compared to a reference population. Moreover, our study shows that direct hospital-related healthcare costs of FRI of the patella were nine times higher compared to non-FRI cases. CONCLUSIONS FRI of the patella is a challenging complication and recurrence of infection not uncommon. Although multiple treatment modalities exist, a multidisciplinary patient-specific approach is crucial. An early or delayed onset infection can be managed with a DAIR approach, but only when the construct is stable and the soft tissue coverage adequate. In patients with an FRI, implant removal is preferred when the fracture has healed. A total patellectomy can be used as a salvage procedure in complex cases with acceptable functional results. Overall, FRI of the patella leads to both a negative impact on the functional status of the patient and a ninefold increase in total healthcare costs.
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Affiliation(s)
- Anton Boeckxstaens
- University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium
| | - Harm Hoekstra
- University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, B-3000 Leuven, Belgium
| | - Melissa Depypere
- University Hospitals Leuven, Department of Laboratory Medicine, B-3000, Leuven, Belgium
| | - Thomas Nevens
- University Hospitals Leuven, Department of Plastic and Reconstructive Surgery, B-3000 Leuven, Belgium
| | - Stefaan Nijs
- University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, B-3000 Leuven, Belgium
| | - Jan J Vranckx
- University Hospitals Leuven, Department of Plastic and Reconstructive Surgery, B-3000 Leuven, Belgium
| | - Willem-Jan Metsemakers
- University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, B-3000 Leuven, Belgium.
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25
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Uyttebroek S, Onsea J, Van Gerven L, Metsemakers WJ. GRADE misuse in systematic reviews - Authors' reply. Lancet Infect Dis 2022; 22:591-592. [PMID: 35460653 DOI: 10.1016/s1473-3099(22)00217-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 03/22/2022] [Indexed: 06/14/2023]
Affiliation(s)
- Saartje Uyttebroek
- Department of Otorhinolaryngology, UZ Leuven, Leuven 3000, Belgium; Department of Neurosciences, Experimental Otorhinolaryngology, Rhinology Research, KU Leuven, Leuven, Belgium
| | - Jolien Onsea
- Department of Trauma Surgery, UZ Leuven, Leuven 3000, Belgium; Department of Development and Regeneration, Locomotor and Neurological Disorders, KU Leuven, Leuven, Belgium
| | - Laura Van Gerven
- Department of Otorhinolaryngology, UZ Leuven, Leuven 3000, Belgium; Department of Neurosciences, Experimental Otorhinolaryngology, Rhinology Research, KU Leuven, Leuven, Belgium; Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology Research Group, KU Leuven, Leuven, Belgium
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, UZ Leuven, Leuven 3000, Belgium; Department of Development and Regeneration, Locomotor and Neurological Disorders, KU Leuven, Leuven, Belgium.
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Mertens B, Van Daele R, Depypere M, Lagrou K, Debaveye Y, Wauters J, Nijs S, Metsemakers WJ, Spriet I. Isavuconazole in the Treatment of Aspergillus fumigatus Fracture-Related Infection: Case Report and Literature Review. Antibiotics (Basel) 2022; 11:antibiotics11030344. [PMID: 35326807 PMCID: PMC8944859 DOI: 10.3390/antibiotics11030344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 02/21/2022] [Accepted: 02/25/2022] [Indexed: 02/06/2023] Open
Abstract
Aspergillus fracture-related infection (FRI) is a rare, but severe complication in trauma surgery. The optimal antifungal treatment for Aspergillus osteomyelitis, including FRI, has not been established yet, as only cases have been documented and data on bone penetration of antifungal drugs are scarce. We describe a patient with Aspergillus fumigatus FRI of the tibia who was treated with isavuconazole after developing liver function disturbances during voriconazole therapy. Isavuconazole, the active moiety formed after hydrolysis of the prodrug isavuconazonium sulfate by plasma esterases, was administered in a maintenance dose of 200 mg q24 h, followed by 150 mg q24 h. The patient completed a six-month antifungal treatment course. Although fracture union was not achieved during six months of follow-up after therapy cessation, no confirmatory signs of FRI were observed. Additionally, two literature searches were conducted to review available data on antifungal treatment of Aspergillus osteomyelitis and bone penetration of antifungals. One hundred and eight cases of Aspergillus osteomyelitis, including six (5.6%) FRI cases, were identified. Voriconazole and (lipid formulations of) amphotericin B were the most commonly used antifungals. In three (2.8%) cases isavuconazole was prescribed as salvage therapy. Data on antifungal bone penetration were reported for itraconazole, voriconazole, amphotericin B, anidulafungin and 5-fluorocytosin. Isavuconazole might be a promising alternative for the treatment of Aspergillus osteomyelitis. However, standardized case documentation is needed to evaluate the efficacy of isavuconazole and other antifungals in the treatment of Aspergillus osteomyelitis, including FRI.
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Affiliation(s)
- Beatrijs Mertens
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, B-3000 Leuven, Belgium; (R.V.D.); (I.S.)
- Pharmacy Department, University Hospitals Leuven, B-3000 Leuven, Belgium
- Correspondence: ; Tel.: +32-16-34-69-57
| | - Ruth Van Daele
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, B-3000 Leuven, Belgium; (R.V.D.); (I.S.)
- Pharmacy Department, University Hospitals Leuven, B-3000 Leuven, Belgium
| | - Melissa Depypere
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, B-3000 Leuven, Belgium; (M.D.); (K.L.); (J.W.)
| | - Katrien Lagrou
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, B-3000 Leuven, Belgium; (M.D.); (K.L.); (J.W.)
- Belgian National Reference Center for Mycosis, University Hospitals Leuven, B-3000 Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, B-3000 Leuven, Belgium
| | - Yves Debaveye
- Department of Cellular and Molecular Medicine, KU Leuven, B-3000 Leuven, Belgium;
- Intensive Care Unit, University Hospitals Leuven, B-3000 Leuven, Belgium
| | - Joost Wauters
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, B-3000 Leuven, Belgium; (M.D.); (K.L.); (J.W.)
- Medical Intensive Care Unit, University Hospitals Leuven, B-3000 Leuven, Belgium
| | - Stefaan Nijs
- Department of Development and Regeneration, KU Leuven, B-3000 Leuven, Belgium; (S.N.); (W.-J.M.)
- Department of Trauma Surgery, University Hospitals Leuven, B-3000 Leuven, Belgium
| | - Willem-Jan Metsemakers
- Department of Development and Regeneration, KU Leuven, B-3000 Leuven, Belgium; (S.N.); (W.-J.M.)
- Department of Trauma Surgery, University Hospitals Leuven, B-3000 Leuven, Belgium
| | - Isabel Spriet
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, B-3000 Leuven, Belgium; (R.V.D.); (I.S.)
- Pharmacy Department, University Hospitals Leuven, B-3000 Leuven, Belgium
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Uyttebroek S, Chen B, Onsea J, Ruythooren F, Debaveye Y, Devolder D, Spriet I, Depypere M, Wagemans J, Lavigne R, Pirnay JP, Merabishvili M, De Munter P, Peetermans WE, Dupont L, Van Gerven L, Metsemakers WJ. Safety and efficacy of phage therapy in difficult-to-treat infections: a systematic review. The Lancet Infectious Diseases 2022; 22:e208-e220. [DOI: 10.1016/s1473-3099(21)00612-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/26/2021] [Accepted: 09/10/2021] [Indexed: 12/11/2022]
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Coopmans L, Amaya Aliaga J, Metsemakers WJ, Sermon A, Misselyn D, Nijs S, Hoekstra H. Accelerated Rehabilitation in Non-operative Management of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis. J Foot Ankle Surg 2022; 61:157-162. [PMID: 34400090 DOI: 10.1053/j.jfas.2021.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 07/10/2021] [Indexed: 02/03/2023]
Abstract
The optimal treatment and rehabilitation strategy for Achilles tendon ruptures is still under debate. There is a paradigm shift toward early mobilization and weightbearing. We examined the treatment effect of accelerated functional rehabilitation in nonoperative management of acute Achilles tendon ruptures. A systematic search of PubMed, EMBASE, and Web of Science databases for articles comparing accelerated versus delayed rehabilitation in the nonoperative management of acute Achilles tendon rupture was performed. Outcomes of interest were Achilles tendon rupture score (ATRS) (standardized patient-reported instrument related to symptoms and physical activity after treatment of an acute Achilles tendon rupture), rerupture rate, strength, range of motion, return to work, and sports. A total of 2001 articles were identified using our search strategy. We included 6 randomized controlled trials of interest. Although the concept of accelerated rehabilitation has gained popularity in recent years, no statistically significant differences could be revealed in any of the outcomes of interest. We performed a meta-analysis on the following outcomes: ATRS (mean difference -0.93 95% confidence interval [CI] -6.01 to 4.14), Rerupture rate (odds ratio [OR] 0.97, 95% CI: 0.46-2.03), Return to sports (OR 1.31, 95% CI 0.76-2.25), Return to work (mean difference 5.24, 95% CI to -12.04 to 22.51). The treatment effect of accelerated rehabilitation in nonoperatively treated patients seems to be small. However, we recommend accelerated rehabilitation for all conservatively treated patients, because it is a safe option and no detrimental effects have been described in the literature. Furthermore, many patients prefer this type of rehabilitation to avoid the practical disadvantages of prolonged immobilization.
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Affiliation(s)
- Laurens Coopmans
- Faculty of Medicine, KU Leuven - University of Leuven, Leuven, Belgium
| | - Jorge Amaya Aliaga
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Orthopaedics and Traumatology, VU Brussel - Free University of Brussels, Brussels, Belgium
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven - University of Leuven, Leuven, Belgium
| | - An Sermon
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven - University of Leuven, Leuven, Belgium
| | - Dominique Misselyn
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Stefaan Nijs
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven - University of Leuven, Leuven, Belgium
| | - Harm Hoekstra
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven - University of Leuven, Leuven, Belgium.
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Zalavras CG, Aerden L, Declercq P, Belmans A, Metsemakers WJ. Ninety-Day Follow-up Is Inadequate for Diagnosis of Fracture-related Infections in Patients with Open Fractures. Clin Orthop Relat Res 2022; 480:139-146. [PMID: 34351311 PMCID: PMC8673965 DOI: 10.1097/corr.0000000000001911] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 07/02/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Fracture-related infection (FRI) is a challenging complication in musculoskeletal trauma surgery and often complicates the management of open fractures. The CDC currently advocates a surveillance period of 90 days after fracture fixation, but it is unclear what duration of follow-up constitutes adequate surveillance for FRI. Inadequate follow-up will underestimate infections and, in clinical research, will make any interventions studied appear better than they really are, thereby resulting in misleading conclusions. QUESTIONS/PURPOSES (1) What is the timing of FRI onset in patients with open fractures? (2) What is the proportion of FRIs captured when follow-up is limited to 90 days postoperatively versus when follow-up is extended to 1 year? METHODS This is a secondary analysis of patient data from a previous retrospective cohort study that investigated whether the duration of perioperative antibiotic prophylaxis was independently associated with FRI in patients with open fractures. Of the 530 eligible patients in the source study, 3% (14) died. Of the remaining 516 patients, 97% (502) patients with 559 long-bone open fractures had 2 years of follow-up constituted the base cohort. Forty-seven fractures in 46 patients were complicated by FRI and were the focus of this secondary analysis. Medical records were reviewed in detail specifically for the current study. Seventy-eight percent (36 of 46) of patients were male, and the mean ± SD age was 42 ± 16 years. The most common mechanism of injury was a motor vehicle accident (63% [29 of 46] of patients), and the tibia was the most involved site (53% [25 of 47] of fractures). The median (interquartile range) time to debridement was 3.0 hours (IQR 2.0 to 4.0). FRIs developed in 3% (7 of 247) of Type I open fractures, 7% (11 of 164) of Type II, 17% (18 of 107) of Type IIIA, 29% (9 of 31) of Type IIIB, and 20% (2 of 10) of Type IIIC open fractures. Each clinic visit of each patient was reviewed, and data about the time of onset of any symptoms and signs suggesting or confirming an FRI, as reported by patients and/or determined by treating surgeons, were recorded. The proportions of FRIs with onset by specific time periods were determined. A Kaplan-Meier survival analysis was performed, and the FRI event rates with 95% confidence intervals were calculated. RESULTS The median (IQR) time to the onset of FRI was 52 days (IQR 15 to 153). Follow-up of 90 days captured only 64% (30 of 47) of FRIs, whereas follow-up of 1 year captured 89% (42 of 47) of FRIs. The proportion of FRIs with onset within 1 year increased to 95% (42 of 44) in the presence of an already healed fracture. CONCLUSION Follow-up of 90 days after the management of an open long-bone fracture is inadequate for postoperative surveillance, especially for research purposes. Clinical research on interventions would report results appearing to be much better than they really are, potentially resulting in misleading conclusions. Follow-up of 1 year is preferable because most FRIs will develop before that time, especially when fracture union has occurred. A small percentage of patients may still develop infections beyond the first year after the management of an open fracture. The risk of missing these infections by not extending follow-up beyond 1 year must be balanced against the additional logistical burden. Future prospective multicenter studies and registries with long-term patient follow-up would help clarify this issue.Level of Evidence Level III, diagnostic study.
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Affiliation(s)
- Charalampos G. Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Laurens Aerden
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Peter Declercq
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- KU Leuven – Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, University of Leuven, Leuven, Belgium
| | - Ann Belmans
- KU Leuven – University of Leuven & Universiteit Hasselt, I-BioStat, Leuven, Belgium
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
- KU Leuven – Department of Development and Regeneration, University of Leuven, Leuven, Belgium
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Mufty H, Van Den Eynde J, Meuris B, Metsemakers WJ, Van Wijngaerden E, Vandendriessche T, Steenackers HP, Fourneau I. Pre-clinical In Vitro Models of Vascular Graft Coating in the Prevention of Vascular Graft Infection: A Systematic Review. Eur J Vasc Endovasc Surg 2022; 63:119-137. [PMID: 34674936 DOI: 10.1016/j.ejvs.2021.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 07/10/2021] [Accepted: 07/25/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Vascular graft infection (VGI) is a feared complication. Prevention is of the utmost importance and vascular graft coatings (VGCs) could offer a potential to do this, with in vitro research a first crucial step. The aim of this study was to summarise key features of in vitro models investigating coating strategies to prevent VGI in order to provide guidance for the setup of future translational research. DATA SOURCES A comprehensive search was performed in MEDLINE, Embase, and Web of Science. METHODS A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. For each database, a specific search strategy was developed. Quality was assessed with the Toxicological data Reliability Assessment Tool (ToxRTool). In vitro models using a VGC and inoculation of the graft with a pathogen were included. The type of graft, coating, and pathogen were summarised. The outcome assessment in each study was evaluated. RESULTS In total, 4 667 studies were identified, of which 45 papers met the inclusion criteria. The majority used polyester grafts (68.2%). Thirty-one studies (68.9%) included antibiotics, and nine studies (20%) used a commercial silver graft in their protocol. New antibacterial strategies (e.g., proteolytic enzymes) were investigated. A variety of testing methods was found and focused mainly on bacterial adherence, coating adherence and dilution, biofilm formation, and cytotoxicity. Ninety-three per cent of the studies (n = 41) were considered unreliable. CONCLUSION Polyester is the preferred type of graft to coat on. The majority of coating studies are based on antibiotics; however, new coating strategies (e.g., antibiofilm coating) are coming. Many in vitro setups are available. In vitro studies have great potential, they can limit the use, but cannot replace in vivo studies completely. This paper can be used as a guidance document for future in vitro research.
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Affiliation(s)
- Hozan Mufty
- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Research Unit of Vascular Surgery, KU Leuven, Leuven, Belgium.
| | - Jef Van Den Eynde
- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Research Unit of Vascular Surgery, KU Leuven, Leuven, Belgium
| | - Bart Meuris
- Department of Cardiovascular Sciences, Research Unit of Vascular Surgery, KU Leuven, Leuven, Belgium; Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - Eric Van Wijngaerden
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | | | - Hans P Steenackers
- Department of Microbial and Molecular Systems, Centre of Microbial and Plant Genetics, KU Leuven, Leuven, Belgium
| | - Inge Fourneau
- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Research Unit of Vascular Surgery, KU Leuven, Leuven, Belgium
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Onsea J, Post V, Buchholz T, Schwegler H, Zeiter S, Wagemans J, Pirnay JP, Merabishvili M, D’Este M, Rotman SG, Trampuz A, Verhofstad MHJ, Obremskey WT, Lavigne R, Richards RG, Moriarty TF, Metsemakers WJ. Bacteriophage Therapy for the Prevention and Treatment of Fracture-Related Infection Caused by Staphylococcus aureus: a Preclinical Study. Microbiol Spectr 2021; 9:e0173621. [PMID: 34908439 PMCID: PMC8672900 DOI: 10.1128/spectrum.01736-21] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 11/09/2021] [Indexed: 12/23/2022] Open
Abstract
Although several studies have shown promising clinical outcomes of phage therapy in patients with orthopedic device-related infections, questions remain regarding the optimal application protocol, systemic effects, and the impact of the immune response. This study provides a proof-of-concept of phage therapy in a clinically relevant rabbit model of fracture-related infection (FRI) caused by Staphylococcus aureus. In a prevention setting, phage in saline (without any biomaterial-based carrier) was highly effective in the prevention of FRI, compared to systemic antibiotic prophylaxis alone. In the subsequent study involving treatment of established infection, daily administration of phage in saline through a subcutaneous access tube was compared to a single intraoperative application of a phage-loaded hydrogel and a control group receiving antibiotics only. In this setting, although a possible trend of bacterial load reduction on the implant was observed with the phage-loaded hydrogel, no superior effect of phage therapy was found compared to antibiotic treatment alone. The application of phage in saline through a subcutaneous access tube was, however, complicated by superinfection and the development of neutralizing antibodies. The latter was not found in the animals that received the phage-loaded hydrogel, which may indicate that encapsulation of phages into a carrier such as a hydrogel limits their exposure to the adaptive immune system. These studies show phage therapy can be useful in targeting orthopedic device-related infection, however, further research and improvements of these application methods are required for this complex clinical setting. IMPORTANCE Because of the growing spread of antimicrobial resistance, the use of alternative prevention and treatment strategies is gaining interest. Although the therapeutic potential of bacteriophages has been demonstrated in a number of case reports and series over the past decade, many unanswered questions remain regarding the optimal application protocol. Furthermore, a major concern during phage therapy is the induction of phage neutralizing antibodies. This study aimed at providing a proof-of-concept of phage therapy in a clinically relevant rabbit model of fracture-related infection caused by Staphylococcus aureus. Phage therapy was applied as prophylaxis in a first phase, and as treatment of an established infection in a second phase. The development of phage neutralizing antibodies was evaluated in the treatment study. This study demonstrates that phage therapy can be useful in targeting orthopedic device-related infection, especially as prophylaxis; however, further research and improvements of these application methods are required.
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Affiliation(s)
- Jolien Onsea
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | | | | | | | | | | | - Jean-Paul Pirnay
- Laboratory for Molecular and Cellular Technology, Queen Astrid Military Hospital, Brussels, Belgium
| | - Maya Merabishvili
- Laboratory for Molecular and Cellular Technology, Queen Astrid Military Hospital, Brussels, Belgium
| | | | | | - Andrej Trampuz
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Michael H. J. Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - William T. Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Rob Lavigne
- Laboratory of Gene Technology, KU Leuven, Leuven, Belgium
| | | | | | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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Mufty H, Van den Bergh M, Meuris B, Metsemakers WJ, Fourneau I. Clinical Studies Reporting on Vascular Graft Coatings for the Prevention of Aortic Graft Infection: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2021; 63:112-118. [PMID: 34801385 DOI: 10.1016/j.ejvs.2021.09.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 09/08/2021] [Accepted: 09/19/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the efficacy of vascular graft coatings used in the aortic position to prevent vascular graft infection (VGI). METHODS A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines using a pre-registered protocol (CRD42020206436). Eligible studies used a vascular graft coating in the aortic position and reported on VGI. A search was performed in MEDLINE (PubMed), Embase, Web of Science, and the Cochrane Library. Primary outcome parameters were VGI, patency, and mortality. Pooled estimates of VGI were calculated using odds ratio (OR) and 95% confidence intervals (CIs) wherever possible. Quality assessment was performed with the Newcastle-Ottawa Assessment Scale and the Revised Cochrane risk of bias tool for randomised trials. RESULTS In total, 6 873 papers were identified. Only eight studies were included. Six of eight studies (75%) reported on known antimicrobial coating strategies such as antibiotics (n = 3) and silver (n = 3). In the other two studies, polymer coated grafts were used. Only three of eight studies compared coated with uncoated grafts (two antibiotic and one silver). Two randomised controlled trials reported on the effect of rifampicin soaked (1 mg/mL) grafts and showed no significant effect in the early (2 months; OR 0.69, 95% CI 0.29 - 1.62) or late (2 years; OR 0.73, 95% CI 0.23 - 2.32) post-operative periods. A retrospective cohort study focusing on the effect of silver coated grafts did not reveal any advantage (OR 0.19, 95% CI 0.02 - 1.64). Two polymer coated grafts were not considered to have a potential benefit in the prevention of VGIs. CONCLUSION Clinical studies reporting on the antibacterial effect of vascular graft coatings in the aortic position to prevent VGI are scarce. For silver and antibiotic coatings, no significant protection for VGI was observed. New types of grafts or long acting coating strategies are mandatory to prevent this complication in the future.
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Affiliation(s)
- Hozan Mufty
- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Research Unit of Vascular Surgery, KU Leuven, Leuven, Belgium.
| | - Mats Van den Bergh
- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Research Unit of Vascular Surgery, KU Leuven, Leuven, Belgium
| | - Bart Meuris
- Department of Cardiovascular Sciences, Research Unit of Vascular Surgery, KU Leuven, Leuven, Belgium; Department of Cardiac surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - Inge Fourneau
- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Research Unit of Vascular Surgery, KU Leuven, Leuven, Belgium
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Wittauer M, Burch MA, McNally M, Vandendriessche T, Clauss M, Della Rocca GJ, Giannoudis PV, Metsemakers WJ, Morgenstern M. Definition of long-bone nonunion: A scoping review of prospective clinical trials to evaluate current practice. Injury 2021; 52:3200-3205. [PMID: 34531088 DOI: 10.1016/j.injury.2021.09.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 09/06/2021] [Indexed: 02/02/2023]
Abstract
AIM Although nonunions are among the most common complications after long-bone fracture fixation, the definition of fracture nonunion remains controversial and varies widely. The aim of this study was to identify the definitions and diagnostic criteria used in the scientific literature to describe nonunions after long-bone fractures. METHODS A comprehensive literature search was performed in PubMed, Cochrane Library, Web of Science, and Embase. Prospective clinical studies, in which adult long-bone fracture nonunions were investigated as main subject, were included in this analysis. Data on nonunion definitions described in each study were extracted and collected in a database. RESULTS Although 148 studies met the inclusion criteria, only 50% (74/148) provided a definition for their main study subject. Nonunion was defined in these studies based on time-related criteria in 85% (63/74), on radiographic criteria in 62% (46/74), and on clinical criteria in 45% (33/74). A combination of clinical, radiographic and time-related criteria for definition was found in 38% (28/74). The time interval between fracture and the time point when authors defined an unhealed fracture as a nonunion showed considerable heterogeneity, ranging from three to twelve months. CONCLUSION In the current orthopaedic literature, we found a lack of consensus with regard to the definition of long-bone nonunions. Without valid and reliable definition criteria for nonunion, standardization of diagnostic and treatment algorithms as well as the comparison of clinical studies remains problematic. The lack of a clear definition emphasizes the need for a consensus-based approach to the diagnosis of fracture nonunion centred on clinical, radiographical and time-related criteria.
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Affiliation(s)
- Matthias Wittauer
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland, Spitalstrasse 21, 4031 Basel, Switzerland; University of Basel, Petersplatz 1, 4001 Basel, Switzerland
| | - Marc-Antoine Burch
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland, Spitalstrasse 21, 4031 Basel, Switzerland; University of Basel, Petersplatz 1, 4001 Basel, Switzerland
| | - Martin McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Windmill Rd, Oxford OX3 7LD, UK
| | - Thomas Vandendriessche
- KU Leuven Libraries - 2Bergen - Learning Centre Désiré Collen, Herestraat 49, 3000 Leuven, Belgium
| | - Martin Clauss
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland, Spitalstrasse 21, 4031 Basel, Switzerland; University of Basel, Petersplatz 1, 4001 Basel, Switzerland
| | - Gregory J Della Rocca
- Department of Orthopaedic Surgery, University of Missouri, 1 Hospital Dr, Columbia, MO, 65201, USA
| | - Peter V Giannoudis
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds LS2 9JT, UK; NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Chapeltown Rd, Leeds LS7 4SA, UK
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven; Department of Development and Regeneration, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Mario Morgenstern
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland, Spitalstrasse 21, 4031 Basel, Switzerland; University of Basel, Petersplatz 1, 4001 Basel, Switzerland.
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Lemmens L, Geelen H, Depypere M, De Munter P, Verhaegen F, Zimmerli W, Nijs S, Debeer P, Metsemakers WJ. Management of periprosthetic infection after reverse shoulder arthroplasty. J Shoulder Elbow Surg 2021; 30:2514-2522. [PMID: 33895302 DOI: 10.1016/j.jse.2021.04.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/29/2021] [Accepted: 04/04/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Periprosthetic shoulder infection (PSI) remains a devastating complication after reverse shoulder arthroplasty (RSA). Currently, scientific data related to the management of PSI are limited, and the optimal strategy and related clinical outcomes remain unclear. Guidelines from the Infectious Diseases Society of America for the management of periprosthetic joint infection are mainly based on data from patients after hip and knee arthroplasty. The aim of this study was to evaluate whether these guidelines are also valid for patients with PSI after RSA. In addition, the functional outcome according to the surgical intervention was assessed. METHODS An RSA database was retrospectively reviewed to identify infections after primary and revision RSAs, diagnosed between 2004 and 2018. Data collected included age, sex, indication for RSA, causative pathogen, surgical and antimicrobial treatment, functional outcome, and recurrence. RESULTS Thirty-six patients with a PSI were identified. Surgical treatment was subdivided into débridement and implant retention (DAIR) (n = 6, 17%); 1-stage revision (n = 1, 3%); 2-stage revision (n = 16, 44%); multiple-stage revision (>2 stages) (n = 7, 19%); definitive spacer implantation (n = 2, 6%); and resection arthroplasty (n = 4, 11%). The most common causative pathogens were Staphylococcus epidermidis (n = 11, 31%) and Cutibacterium acnes (n = 9, 25%). Recurrence was diagnosed in 4 patients (11%), all of whom were initially treated with a DAIR approach. The median follow-up period was 36 months (range, 24-132 months). CONCLUSION PSI is typically caused by low-virulence pathogens, which often are diagnosed with a delay, resulting in chronic infection at the time of surgery. Our results indicate that treatment of patients with chronic PSI with DAIR has a high recurrence rate. In addition, implant exchange (ie, 1- and 2-stage exchange) does not compromise the functional result as compared with implant retention. Thus, patients with chronic PSI should be treated with implant exchange. Future research should further clarify which surgical strategy (ie, 1-stage vs. 2-stage exchange) has a better outcome overall.
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Affiliation(s)
- Laura Lemmens
- Department of Orthopaedics, University Hospitals Leuven, Leuven, Belgium
| | - Hans Geelen
- Department of Orthopaedics, University Hospitals Leuven, Leuven, Belgium
| | - Melissa Depypere
- Department of Clinical Biology, University Hospitals Leuven, Leuven, Belgium
| | - Paul De Munter
- Department of Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Filip Verhaegen
- Department of Orthopaedics, University Hospitals Leuven, Leuven, Belgium
| | - Werner Zimmerli
- Interdisciplinary Unit for Orthopaedic Infections, Kantonsspital Baselland, Liestal, Switzerland
| | - Stefaan Nijs
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
| | - Philippe Debeer
- Department of Orthopaedics, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium.
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Iliaens J, Onsea J, Hoekstra H, Nijs S, Peetermans WE, Metsemakers WJ. Fracture-related infection in long bone fractures: A comprehensive analysis of the economic impact and influence on quality of life. Injury 2021; 52:3344-3349. [PMID: 34474918 DOI: 10.1016/j.injury.2021.08.023] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 08/18/2021] [Accepted: 08/19/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Fracture-related infection (FRI) is a feared complication with substantial clinical and economic consequences. The main objective of this study was to compare direct and indirect healthcare costs related to long bone fractures in patients with and without FRI and to assess its impact on the patient's quality of life (QoL). PATIENTS AND METHODS Between January 2015 and March 2019, 175 patients with FRI were treated at the University Hospitals Leuven (Belgium). Using a matched-pair analysis, patients with an FRI were matched by age, sex, and fracture location (humeral, femoral, or tibial shaft) to a non-FRI cohort treated during the same time period. Clinical and process-related variables, direct hospital-related healthcare costs, and indirect costs due to absenteeism were compared between the two groups. Furthermore, the patient's QoL was evaluated using Patient-Reported Outcomes Measurement Information System (PROMIS) physical function and pain interference. RESULTS After matched-pair analysis, 15 patients in both the FRI and non-FRI group were included. FRI was associated with direct hospital-related costs being eight times that of non-FRI patients (€ 47,845 [€ 43,072-€ 82,548] vs. € 5,983 [€ 4,519-€ 8,428], p < 0.001). Furthermore, FRI was associated with prolonged absenteeism (340 [340-676] vs. 86 [65-216] days, p = 0.007) and a median indirect cost that was nearly four times that of patients without FRI (€ 77,909 vs. € 19,706). Lastly, FRI patients showed significantly poorer outcomes on both physical function (35.6 vs. 48.4, p < 0.001) and pain interference (60.4 vs. 46.3, p < 0.001) PROMIS scales. CONCLUSION Direct hospital-related healthcare costs of FRI are eight times that of non-FRI long bone fractures. Total healthcare costs are mainly driven by hospitalisation costs, wherein FRI is associated with prolonged length of stay. To the best of our knowledge, this study is the first to demonstrate that FRI is also associated with substantial absenteeism, which is almost four times higher compared to non-FRI patients. In addition to this economic impact, FRI significantly deteriorates QoL. Generalizing the outcome of this study should be done cautiously due to the small sample size of 15 patients in both the FRI and non-FRI group after matched-pair analysis.
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Affiliation(s)
- Jorien Iliaens
- Department of Trauma Surgery, University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium
| | - Jolien Onsea
- Department of Trauma Surgery, University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium; Department of Development and Regeneration, KU Leuven, Belgium
| | - Harm Hoekstra
- Department of Trauma Surgery, University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium; Department of Development and Regeneration, KU Leuven, Belgium
| | - Stefaan Nijs
- Department of Trauma Surgery, University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium; Department of Development and Regeneration, KU Leuven, Belgium
| | - Willy E Peetermans
- Department of general internal medicine, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology and Transplantation, Laboratory of clinical infectious and inflammatory disease, KU Leuven, Belgium
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium; Department of Development and Regeneration, KU Leuven, Belgium.
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Haidari S, IJpma FFA, Metsemakers WJ, Maarse W, Vogely HC, Ramsden AJ, McNally MA, Govaert GAM. The Role of Negative-Pressure Wound Therapy in Patients with Fracture-Related Infection: A Systematic Review and Critical Appraisal. Biomed Res Int 2021; 2021:7742227. [PMID: 34722772 PMCID: PMC8548908 DOI: 10.1155/2021/7742227] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/07/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Fracture-related infection (FRI) is a severe musculoskeletal complication in orthopedic trauma surgery, causing challenges in bony and soft tissue management. Currently, negative-pressure wound therapy (NPWT) is often used as temporary coverage for traumatic and surgical wounds, also in cases of FRI. However, controversy exists about the impact of NPWT on the outcome in FRI, specifically on infection recurrence. Therefore, this systematic review qualitatively assesses the literature on the role of NPWT in the management of FRI. METHODS A literature search of the PubMed, Embase, and Web of Science database was performed. Studies that reported on infection recurrence related to FRI management combined with NPWT were eligible for inclusion. Quality assessment was done using the PRISMA statement and the Newcastle-Ottawa Quality Assessment Scale. RESULTS After screening and quality assessment of 775 unique identified records, eight articles could be included for qualitative synthesis. All eight studies reported on infection recurrence, which ranged from 2.8% to 34.9%. Six studies described wound healing time, varying from two to seven weeks. Four studies took repeated microbial swabs during subsequent vacuum dressing changes. One study reported newly detected pathogens in 23% of the included patients, and three studies did not find new pathogens. CONCLUSION This review provides an assessment of current literature on the role of NPWT in the management of soft tissue defects in patients with FRI. Due to the lack of uniformity in included studies, conclusions should be drawn with caution. Currently, there is no clear scientific evidence to support the use of NPWT as definitive treatment in FRI. At this stage, we can only recommend early soft tissue coverage (within days) with a local or free flap. NPWT may be safe for a few days as temporarily soft tissue coverage until definitive soft tissue management could be performed. However, comparative studies between NPWT and early wound closure in FRI patients are needed.
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Affiliation(s)
- Susan Haidari
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Frank F. A. IJpma
- Department of Trauma Surgery, University Medical Center Groningen, Groningen, Netherlands
| | | | - Wies Maarse
- Department of Plastic, Reconstructive and Hand Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - H. Charles Vogely
- Department of Orthopedic Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Alex J. Ramsden
- Department of Plastic and Reconstructive Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Bone Infection Unit, Nuffield Orthopedic Centre, Oxford, UK
| | | | - Geertje A. M. Govaert
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, Netherlands
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Onsea J, Uyttebroek S, Chen B, Wagemans J, Lood C, Van Gerven L, Spriet I, Devolder D, Debaveye Y, Depypere M, Dupont L, De Munter P, Peetermans WE, van Noort V, Merabishvili M, Pirnay JP, Lavigne R, Metsemakers WJ. Bacteriophage Therapy for Difficult-to-Treat Infections: The Implementation of a Multidisciplinary Phage Task Force ( The PHAGEFORCE Study Protocol). Viruses 2021; 13:1543. [PMID: 34452408 PMCID: PMC8402896 DOI: 10.3390/v13081543] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 07/29/2021] [Accepted: 08/02/2021] [Indexed: 12/22/2022] Open
Abstract
In times where only a few novel antibiotics are to be expected, antimicrobial resistance remains an expanding global health threat. In case of chronic infections caused by therapy-resistant pathogens, physicians have limited therapeutic options, which are often associated with detrimental consequences for the patient. This has resulted in a renewed interest in alternative strategies, such as bacteriophage (phage) therapy. However, there are still important hurdles that currently impede the more widespread implementation of phage therapy in clinical practice. First, the limited number of good-quality case series and clinical trials have failed to show the optimal application protocol in terms of route of administration, frequency of administration, treatment duration and phage titer. Second, there is limited information on the systemic effects of phage therapy. Finally, in the past, phage therapy has been applied intuitively in terms of the selection of phages and their combination as parts of phage cocktails. This has led to an enormous heterogeneity in previously published studies, resulting in a lack of reliable safety and efficacy data for phage therapy. We hereby present a study protocol that addresses these scientific hurdles using a multidisciplinary approach, bringing together the experience of clinical, pharmaceutical and molecular microbiology experts.
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Affiliation(s)
- Jolien Onsea
- Department of Trauma Surgery, University Hospitals Leuven, 3000 Leuven, Belgium; (B.C.); (W.-J.M.)
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
| | - Saartje Uyttebroek
- Department of Otorhinolaryngology, University Hospitals Leuven, 3000 Leuven, Belgium; (S.U.); (L.V.G.)
- Department of Neurosciences, Experimental Otorhinolaryngology, Rhinology Research, KU Leuven, 3000 Leuven, Belgium
| | - Baixing Chen
- Department of Trauma Surgery, University Hospitals Leuven, 3000 Leuven, Belgium; (B.C.); (W.-J.M.)
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
| | - Jeroen Wagemans
- Department of Biosystems, Laboratory of Gene Technology, KU Leuven, 3000 Leuven, Belgium; (J.W.); (C.L.); (R.L.)
| | - Cédric Lood
- Department of Biosystems, Laboratory of Gene Technology, KU Leuven, 3000 Leuven, Belgium; (J.W.); (C.L.); (R.L.)
- Center of Microbial and Plant Genetics, KU Leuven, 3000 Leuven, Belgium;
| | - Laura Van Gerven
- Department of Otorhinolaryngology, University Hospitals Leuven, 3000 Leuven, Belgium; (S.U.); (L.V.G.)
- Department of Neurosciences, Experimental Otorhinolaryngology, Rhinology Research, KU Leuven, 3000 Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology Research Group, KU Leuven, 3000 Leuven, Belgium
| | - Isabel Spriet
- Pharmacy Department, University Hospitals Leuven, 3000 Leuven, Belgium; (I.S.); (D.D.)
- Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, 3000 Leuven, Belgium
| | - David Devolder
- Pharmacy Department, University Hospitals Leuven, 3000 Leuven, Belgium; (I.S.); (D.D.)
- Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, 3000 Leuven, Belgium
| | - Yves Debaveye
- Department of Intensive Care Medicine, University Hospitals Leuven, 3000 Leuven, Belgium;
| | - Melissa Depypere
- Department of Laboratory Medicine, University Hospitals Leuven, 3000 Leuven, Belgium;
- Laboratory of Clinical Bacteriology and Mycology, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium
| | - Lieven Dupont
- Department of Pneumology, University Hospitals Leuven, 3000 Leuven, Belgium;
| | - Paul De Munter
- Department of Internal Medicine, University Hospitals Leuven, 3000 Leuven, Belgium; (P.D.M.); (W.E.P.)
- Laboratory for Clinical Infectious and Inflammatory Disorders, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium
| | - Willy E. Peetermans
- Department of Internal Medicine, University Hospitals Leuven, 3000 Leuven, Belgium; (P.D.M.); (W.E.P.)
- Laboratory for Clinical Infectious and Inflammatory Disorders, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium
| | - Vera van Noort
- Center of Microbial and Plant Genetics, KU Leuven, 3000 Leuven, Belgium;
- Institute of Biology, Leiden University, 2333 BE Leiden, The Netherlands
| | - Maia Merabishvili
- Laboratory for Molecular and Cellular Technology, Queen Astrid Military Hospital, 1120 Brussels, Belgium; (M.M.); (J.-P.P.)
| | - Jean-Paul Pirnay
- Laboratory for Molecular and Cellular Technology, Queen Astrid Military Hospital, 1120 Brussels, Belgium; (M.M.); (J.-P.P.)
| | - Rob Lavigne
- Department of Biosystems, Laboratory of Gene Technology, KU Leuven, 3000 Leuven, Belgium; (J.W.); (C.L.); (R.L.)
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, 3000 Leuven, Belgium; (B.C.); (W.-J.M.)
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
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Franz D, Raschke M, Giannoudis PV, Leliveld M, Metsemakers WJ, Verhofstad MHJ, Craig JA, Shore J, Smith A, Muehlendyck C, Kerstan M, Fuchs T. Use of antibiotic coated intramedullary nails in open tibia fractures: A European medical resource use and cost-effectiveness analysis. Injury 2021; 52:1951-1958. [PMID: 34001375 DOI: 10.1016/j.injury.2021.04.053] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 03/01/2021] [Accepted: 04/12/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE In patients with open tibial fractures, bone and wound infections are associated with an increased hospital length of stay and higher costs. The infection risk increases with the use of implants. Innovations to reduce this risk include antibiotic-coated implants. This study models whether the use of a gentamicin-coated intramedullary tibial nail is cost-effective for trauma centers managing patients with a high risk of infection. EFFICACY Absolute infection risk and relative risk reduction, by fracture grade, for antibiotic-coated nails compared to standard nails for patients with open tibial fractures were estimated based on the results of a meta-analysis, which assessed the additional benefit of locally-administered prophylactic antibiotics in open tibia fractures treated with implants. The observed efficacy of antibiotic-coated nails in reducing infections was applied in an economic model. METHODS The model compared infection rates, inpatient days, theatre usage and costs in high risk patients, with a Gustilo-Anderson (GA) grade III open fracture, for two patient cohorts from a trauma center perspective, with a 1-year time horizon. In one cohort all GAIII patients received a gentamicin-coated nail whilst GAI and GAII patients received a standard nail. All patients in the comparator cohort received a standard nail. Four European trauma centers provided patient-level data (n=193) on inpatient days, procedures and related costs for patients with and without infections. RESULTS Using the gentamicin-coated nail in patients at high risk of infection (GAIII) was associated with 75% lower rate of infection and cost savings (€477 - €3.263) for all included centers; the higher cost of the implant was offset by savings from fewer infections, inpatient days (-26%) and re-operations (-10%). This result was confirmed by extensive sensitivity analyses. CONCLUSIONS Analyses demonstrated that infection rates and total costs for in-hospital treatment could be potentially reduced by 75% and up to 15% respectively, by using a gentamicin-coated nail in patients at high risk of infection. Fewer infections, reduced inpatient days and re-operations may be potentially associated with use of antibiotic-coated implants. Results are sensitive to the underlying infection risk, with greatest efficacy and cost-savings when the coated implant is used in high risk patients.
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Affiliation(s)
- D Franz
- Franz und Wenke, Beratung im Gesundheitswesen GbR, Technologiehof Mendelstraße 11, 48149 Münster, Germany.
| | - M Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Germany.
| | - P V Giannoudis
- Department of Trauma and Orthopaedic Surgery, University Hospital of Leeds, England.
| | - M Leliveld
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, the Netherlands.
| | - W J Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Belgium.
| | - M H J Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, the Netherlands.
| | - J A Craig
- York Health Economics Consortium, University of York, York, UK, YO10 5NQ.
| | - J Shore
- York Health Economics Consortium, University of York, York, UK, YO10 5NQ.
| | - A Smith
- Health Economics Consortium, University of York, York, UK, YO10 5NQ.
| | - C Muehlendyck
- J&J, Hummelsbutteler Steindamm 71, 22851 Norderstedt, Germany.
| | - M Kerstan
- J&J, Synthes GmbH, Luzernstrasse 21, 4528 Zuchwil, Switzerland.
| | - T Fuchs
- Vivantes Klinikum im Friedrichshain, Zentrum für Muskuloskelettale Medizin, Klinik für Orthopädie, Unfall-, Hand- und Wiederherstellungschirurgie Standort Landsberger Allee 49, 10249 Berlin, Germany.
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Uyttebroek S, Onsea J, Metsemakers WJ, Dupont L, Devolder D, Wagemans J, Lavigne R, Spriet I, Van Gerven L. The Potential Role of Bacteriophages in the Treatment of Recalcitrant Chronic Rhinosinusitis. Antibiotics (Basel) 2021; 10:antibiotics10060675. [PMID: 34198741 PMCID: PMC8229554 DOI: 10.3390/antibiotics10060675] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/26/2021] [Accepted: 06/02/2021] [Indexed: 01/28/2023] Open
Abstract
Chronic rhinosinusitis is a common condition affecting 5-12% of the general population worldwide. In a limited number of cases, the disease is recalcitrant to medical and surgical interventions, causing a major impact on physical, social and emotional well-being and increasing pressure on healthcare systems. Biofilm formation and dysbiosis caused by Staphylococcus aureus and Pseudomonas aeruginosa play a role in the pathogenesis of recalcitrant chronic rhinosinusitis. In these cases, a promising treatment alternative is the application of bacteriophages, which are viruses that infect and lyse bacteria. In this review, we appraise the evidence for the use of bacteriophages in the treatment of recalcitrant chronic rhinosinusitis. Additionally, (dis)advantages of bacteriophages and considerations for implementation of phage therapy in otorhinolaryngology practice will be discussed.
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Affiliation(s)
- Saartje Uyttebroek
- Department of Otorhinolaryngology, UZ Leuven, 3000 Leuven, Belgium;
- Department of Neurosciences, Experimental Otorhinolaryngology, Rhinology Research, KU Leuven, 3000 Leuven, Belgium
| | - Jolien Onsea
- Department of Trauma Surgery, UZ Leuven, 3000 Leuven, Belgium; (J.O.); (W.-J.M.)
- Department of Development and Regeneration, Locomotor and Neurological Disorders, KU Leuven, 3000 Leuven, Belgium
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, UZ Leuven, 3000 Leuven, Belgium; (J.O.); (W.-J.M.)
- Department of Development and Regeneration, Locomotor and Neurological Disorders, KU Leuven, 3000 Leuven, Belgium
| | - Lieven Dupont
- Department of Pneumology, UZ Leuven, 3000 Leuven, Belgium;
- Department of Chronic Diseases and Metabolism, Respiratory Diseases and Thoracic Surgery, KU Leuven, 3000 Leuven, Belgium
| | - David Devolder
- Pharmacy Department, UZ Leuven, 3000 Leuven, Belgium; (D.D.); (I.S.)
| | - Jeroen Wagemans
- Department of Biosystems, Laboratory of Gene Technology, KU Leuven, 3000 Leuven, Belgium; (J.W.); (R.L.)
| | - Rob Lavigne
- Department of Biosystems, Laboratory of Gene Technology, KU Leuven, 3000 Leuven, Belgium; (J.W.); (R.L.)
| | - Isabel Spriet
- Pharmacy Department, UZ Leuven, 3000 Leuven, Belgium; (D.D.); (I.S.)
- Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, 3000 Leuven, Belgium
| | - Laura Van Gerven
- Department of Otorhinolaryngology, UZ Leuven, 3000 Leuven, Belgium;
- Department of Neurosciences, Experimental Otorhinolaryngology, Rhinology Research, KU Leuven, 3000 Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology Research Unit, KU Leuven, 3000 Leuven, Belgium
- Correspondence: ; Tel.: +32-16-33-63-41
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Affiliation(s)
- Susanne Baertl
- AO Research Institute Davos, Davos, Switzerland.,Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | | | - Mario Morgenstern
- Center for Musculoskeletal Infections, University Hospital Basel, Basel, Switzerland
| | - Volker Alt
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | | | | | - Katie Young
- AO Research Institute Davos, Davos, Switzerland
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Mufty H, Van den Eynde J, Steenackers HP, Metsemakers WJ, Meuris B, Fourneau I. A systematic review of preclinical data regarding commercial silver-coated vascular grafts. J Vasc Surg 2021; 74:1386-1393.e1. [PMID: 34019984 DOI: 10.1016/j.jvs.2021.04.055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 04/16/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Vascular graft infection (VGI) is a serious complication with high mortality and morbidity rates. Several measures could be taken to decrease this risk, including the use of silver-containing vascular grafts. However, to date, no clinical advantages have been reported. This study reviews the outcome of preclinical studies focusing on the role of commercially available silver-coated grafts in the prevention of VGI. METHODS A systematic review was performed with a focus on the preclinical role of commercially available silver-coated vascular grafts in the prevention and treatment of VGI. A comprehensive search was conducted in Medline, Embase, and Web of Science. RESULTS Nine in vitro and five in vivo studies were included. Two commercial grafts were used (INTERGARD SILVER and Silver Graft). In vitro studies used both gram-positive and gram-negative strains. A positive antimicrobial effect was observed in seven of nine studies (77.8%). A delayed antifungal effect against Candida species was observed in vitro, but disappeared when adding serum proteins. In vivo studies witnessed a microbicidal effect in two out of five studies (40%), but only tested a single causative pathogen (ie, Staphylococcus aureus). CONCLUSIONS Both in vitro and in vivo studies demonstrated conflicting and mixed results concerning the antimicrobial efficacy of commercially available silver-containing grafts in the prevention of VGI. In general, the study setup was heterogeneous in the different articles. Given the lack of convincing preclinical evidence and their poor performance in clinical studies, more data are needed at this time to guide the appropriate use of silver grafts.
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Affiliation(s)
- Hozan Mufty
- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Research Unit of Vascular Surgery, KU Leuven, Leuven, Belgium.
| | - Jef Van den Eynde
- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Research Unit of Vascular Surgery, KU Leuven, Leuven, Belgium
| | - Hans P Steenackers
- Department of Microbial and Molecular Systems, Centre of Microbial and Plant Genetics, KU Leuven, Leuven, Belgium
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Bart Meuris
- Department of Cardiovascular Sciences, Research Unit of Vascular Surgery, KU Leuven, Leuven, Belgium; Department of Cardiac surgery, University Hospitals Leuven, Leuven, Belgium
| | - Inge Fourneau
- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Research Unit of Vascular Surgery, KU Leuven, Leuven, Belgium
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Coppola GA, Onsea J, Moriarty TF, Nehrbass D, Constant C, Zeiter S, Aktan MK, Braem A, Van der Eycken EV, Steenackers HP, Metsemakers WJ. An Improved 2-Aminoimidazole Based Anti-Biofilm Coating for Orthopedic Implants: Activity, Stability, and in vivo Biocompatibility. Front Microbiol 2021; 12:658521. [PMID: 33967997 PMCID: PMC8097006 DOI: 10.3389/fmicb.2021.658521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/19/2021] [Indexed: 12/02/2022] Open
Abstract
Orthopedic device-related infections remain a serious challenge to treat. Central to these infections are bacterial biofilms that form on the orthopedic implant itself. These biofilms shield the bacteria from the host immune system and most common antibiotic drugs, which renders them essentially antibiotic-tolerant. There is an urgent clinical need for novel strategies to prevent these serious infections that do not involve conventional antibiotics. Recently, a novel antibiofilm coating for titanium surfaces was developed based on 5-(4-bromophenyl)-N-cyclopentyl-1-octyl-1H-imidazol-2-amine as an active biofilm inhibitor. In the current study we present an optimized coating protocol that allowed for a 5-fold higher load of this active compound, whilst shortening the manufacturing process. When applied to titanium disks, the newly optimized coating was resilient to the most common sterilization procedures and it induced a 1 log reduction in biofilm cells of a clinical Staphylococcus aureus isolate (JAR060131) in vitro, without affecting the planktonic phase. Moreover, the antibiofilm effect of the coating in combination with the antibiotic cefuroxime was higher than cefuroxime treatment alone. Furthermore, the coating was successfully applied to a human-scale fracture fixation device resulting in a loading that was comparable to the titanium disk model. Finally, an in vivo biocompatibility and healing study in a rabbit osteotomy model indicated that these coated implants did not negatively affect fracture healing or osteointegration. These findings put our technology one step closer to clinical trials, confirming its potential in fighting orthopedic infections without compromising healing.
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Affiliation(s)
- Guglielmo Attilio Coppola
- KU Leuven - Department of Chemistry, Laboratory for Organic & Microwave-Assisted Chemistry (LOMAC), Leuven, Belgium.,KU Leuven - Department of Microbial and Molecular Systems, Centre of Microbial and Plant Genetics (CMPG), Leuven, Belgium
| | - Jolien Onsea
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.,KU Leuven - Department of Development and Regeneration, Leuven, Belgium
| | | | | | | | | | - Merve Kübra Aktan
- KU Leuven - Department of Materials Engineering (MTM), Biomaterials and Tissue Engineering Research Group, Leuven, Belgium
| | - Annabel Braem
- KU Leuven - Department of Materials Engineering (MTM), Biomaterials and Tissue Engineering Research Group, Leuven, Belgium
| | - Erik V Van der Eycken
- KU Leuven - Department of Chemistry, Laboratory for Organic & Microwave-Assisted Chemistry (LOMAC), Leuven, Belgium.,Peoples' Friendship University of Russia, Moscow, Russia
| | - Hans P Steenackers
- KU Leuven - Department of Microbial and Molecular Systems, Centre of Microbial and Plant Genetics (CMPG), Leuven, Belgium
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.,KU Leuven - Department of Development and Regeneration, Leuven, Belgium
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Mufty H, Van Den Eynde J, Meuris B, Metsemakers WJ, Van Wijngaerden E, Vandendriessche T, Steenackers HP, Fourneau I. Pre-clinical in vivo Models of Vascular Graft Coating in the Prevention of Vascular Graft Infection: A Systematic Review. Eur J Vasc Endovasc Surg 2021; 62:99-118. [PMID: 33840577 DOI: 10.1016/j.ejvs.2021.02.054] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 01/26/2021] [Accepted: 02/26/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Vascular graft infection (VGI) remains an important complication with a high mortality and morbidity rate. Currently, studies focusing on the role of vascular graft coatings in the prevention of VGI are scarce. Therefore, the aims of this study were to survey and summarise key features of pre-clinical in vivo models that have been used to investigate coating strategies to prevent VGI and to set up an ideal model that can be used in future preclinical research. DATA SOURCES A systematic review was conducted in accordance with the Preferred reporting items for Systematic Reviews and Meta-Analysis guidelines. A comprehensive search was performed in MEDLINE (PubMed), Embase, and Web of Science. REVIEW METHODS For each database, a specific search strategy was developed. Quality was assessed with the Toxicological data Reliability Assessment Tool (ToxRTool). The type of animal model, graft, coating, and pathogen were summarised. The outcome assessment in each study was evaluated. RESULTS In total, 4 667 studies were identified, of which 94 papers focusing on in vivo testing were included. Staphylococcus aureus was the organism most used (n = 65; 67.7%). Most of the graft types were polyester grafts. Rifampicin was the most frequently used antibiotic coating (n = 43, 48.3%). In the outcome assessment, most studies mentioned colony forming unit count (n = 88; 91.7%) and clinical outcome (n = 72; 75%). According to the ToxRTool, 21 (22.3%, n = 21/94) studies were considered to be not reliable. CONCLUSION Currently published in vivo models are very miscellaneous. More attention should be paid to the methodology of these pre-clinical reports when transferring novel graft coatings into clinical practice. Variables used in pre-clinical reports (bacterial strain, duration of activity coating) do not correspond well to current clinical studies. Based on the results of this review, a proposal for a complete and comprehensive set up for pre-clinical invivo testing of anti-infectious properties of vascular graft coatings was defined.
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Affiliation(s)
- Hozan Mufty
- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Research Unit of Vascular Surgery, KU Leuven, Leuven, Belgium.
| | - Jef Van Den Eynde
- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Research Unit of Vascular Surgery, KU Leuven, Leuven, Belgium
| | - Bart Meuris
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Research Unit of Vascular Surgery, KU Leuven, Leuven, Belgium
| | | | - Eric Van Wijngaerden
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | | | - Hans P Steenackers
- Department of Microbial and Molecular Systems, Centre of Microbial and Plant Genetics, KU Leuven, Leuven, Belgium
| | - Inge Fourneau
- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Research Unit of Vascular Surgery, KU Leuven, Leuven, Belgium
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Onsea J, Pallay J, Depypere M, Moriarty TF, Van Lieshout EMM, Obremskey WT, Sermon A, Hoekstra H, Verhofstad MHJ, Nijs S, Metsemakers WJ. Intramedullary tissue cultures from the Reamer-Irrigator-Aspirator system for diagnosing fracture-related infection. J Orthop Res 2021; 39:281-290. [PMID: 32735351 DOI: 10.1002/jor.24816] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/16/2020] [Accepted: 07/27/2020] [Indexed: 02/04/2023]
Abstract
Fracture-related infection (FRI) is a serious complication following musculoskeletal trauma. Accurate diagnosis and appropriate treatment depend on retrieving adequate deep tissue biopsies for bacterial culture. The aim of this cohort study was to compare intraoperative tissue cultures obtained by the Reamer-Irrigator-Aspirator system (RIA)-system against standard tissue cultures obtained during the same surgical procedure. All patients had long bone fractures of the lower limbs and were assigned to the FRI or Control group based on the FRI consensus definition. The FRI group consisted of 24 patients with confirmed FRI and the Control group consisted of 21 patients with aseptic nonunion or chronic pain (in the absence of other suggestive/confirmatory criteria). Standard tissue cultures and cultures harvested by the RIA-system showed similar results. In the FRI group, standard tissue cultures and RIA cultures revealed relevant pathogens in 67% and 71% of patients, respectively. Furthermore, in four FRI patients, cultures obtained by the RIA-system revealed additional relevant pathogens that were not found by standard tissue culturing, which contributed to the optimization of the treatment plan. In the Control group, there were no false-positive RIA culture results. As a proof-of-concept, this cohort study showed that the RIA-system could have a role in the diagnosis of FRI as an adjunct to standard tissue cultures. Since scientific evidence on the added value of the RIA-system in the management of FRI is currently limited, further research on this topic is required before its routine application in clinical practice.
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Affiliation(s)
- Jolien Onsea
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
| | - Jan Pallay
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Melissa Depypere
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | | | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - William T Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - An Sermon
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
| | - Harm Hoekstra
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
| | - Michael H J Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Stefaan Nijs
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
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Metsemakers WJ, Kortram K, Ferreira N, Morgenstern M, Joeris A, Pape HC, Kammerlander C, Konda S, Oh JK, Giannoudis PV, Egol KA, Obremskey WT, Verhofstad MHJ, Raschke M. Fracture-related outcome study for operatively treated tibia shaft fractures (F.R.O.S.T.): registry rationale and design. BMC Musculoskelet Disord 2021; 22:57. [PMID: 33422025 PMCID: PMC7797092 DOI: 10.1186/s12891-020-03930-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/28/2020] [Indexed: 01/12/2023] Open
Abstract
Background Tibial shaft fractures (TSFs) are among the most common long bone injuries often resulting from high-energy trauma. To date, musculoskeletal complications such as fracture-related infection (FRI) and compromised fracture healing following fracture fixation of these injuries are still prevalent. The relatively high complication rates prove that, despite advances in modern fracture care, the management of TSFs remains a challenge even in the hands of experienced surgeons. Therefore, the Fracture-Related Outcome Study for operatively treated Tibia shaft fractures (F.R.O.S.T.) aims at creating a registry that enables data mining to gather detailed information to support future clinical decision-making regarding the management of TSF’s. Methods This prospective, international, multicenter, observational registry for TSFs was recently developed. Recruitment started in 2019 and is planned to take 36 months, seeking to enroll a minimum of 1000 patients. The study protocol does not influence the clinical decision-making procedure, implant choice, or surgical/imaging techniques; these are being performed as per local hospital standard of care. Data collected in this registry include injury specifics, treatment details, clinical outcomes (e.g., FRI), patient-reported outcomes, and procedure- or implant-related adverse events. The minimum follow up is 12 months. Discussion Although over the past decades, multiple high-quality studies have addressed individual research questions related to the outcome of TSFs, knowledge gaps remain. The scarcity of data calls for an international high-quality, population-based registry. Creating such a database could optimize strategies intended to prevent severe musculoskeletal complications. The main purpose of the F.R.O.S.T registry is to evaluate the association between different treatment strategies and patient outcomes. It will address not only operative techniques and implant materials but also perioperative preventive measures. For the first time, data concerning systemic perioperative antibiotic prophylaxis, the influence of local antimicrobials, and timing of soft-tissue coverage will be collected at an international level and correlated with standardized outcome measures in a large prospective, multicenter, observational registry for global accessibility. Trial registration ClinicalTrials.gov: NCT03598530. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-020-03930-x.
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Affiliation(s)
- Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium. .,Department of Development and Regeneration, KU Leuven, Leuven, Belgium.
| | - Kirsten Kortram
- Trauma Research Unit, Department of Trauma Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nando Ferreira
- Division of Orthopaedics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa
| | - Mario Morgenstern
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Alexander Joeris
- AO Innovation Translation Center, AO Foundation, Dübendorf, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma, UniversitätsSpital Zürich, University of Zurich, Raemistrasse, Zurich, Switzerland
| | - Christian Kammerlander
- Department of General Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Sanjit Konda
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital and Jamaica Hospital Medical Center, New York, NY, USA
| | - Jong-Keon Oh
- Department of Orthopaedic Surgery, Korea University College of Medicine, Guro Hospital, Guro-gu, Seoul, Republic of Korea
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Leeds, UK.,NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, UK
| | - Kenneth A Egol
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - William T Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael H J Verhofstad
- Trauma Research Unit, Department of Trauma Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Michael Raschke
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Muenster, Germany
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Metsemakers WJ, Zalavras C, Schwarz EM, Chen AF, Trampuz A, Moriarty TF. Antimicrobial Resistance, the COVID-19 Pandemic, and Lessons for the Orthopaedic Community. J Bone Joint Surg Am 2021; 103:4-9. [PMID: 33259429 DOI: 10.2106/jbjs.20.01214] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Antimicrobial resistance (AMR) is widely regarded as one of the most important global public health challenges of the twenty-first century. The overuse and the improper use of antibiotics in human medicine, food production, and the environment as a whole have unfortunately contributed to this issue. Many major international scientific, political, and social organizations have warned that the increase in AMR could cost the lives of millions of people if it is not addressed on a global scale. Although AMR is already a challenge in clinical practice today, it has taken on a new importance in the face of the coronavirus disease 2019 (COVID-19) pandemic. While improved handwashing techniques, social distancing, and other interventional measures may positively influence AMR, the widespread use of antibiotics to treat or prevent bacterial coinfections, especially in unconfirmed cases of COVID-19, may have unintended negative implications with respect to AMR. Although the exact number of bacterial coinfections and the rate at which patients with COVID-19 receive antibiotic therapy remain to be accurately determined, the pandemic has revived the discussion on antibiotic overuse and AMR. This article describes why the COVID-19 pandemic has increased our awareness of AMR and presents the immense global impact of AMR on society as a whole. Furthermore, an attempt is made to stress the importance of tackling AMR in the future and the role of the orthopaedic community in this worldwide effort.
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Affiliation(s)
- Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
| | - Charalampos Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Edward M Schwarz
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Antonia F Chen
- Department of Orthopaedics, Brigham and Women's Hospital, Boston, Massachusetts
| | - Andrej Trampuz
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Bezstarosti H, Metsemakers WJ, van Lieshout EMM, Voskamp LW, Kortram K, McNally MA, Marais LC, Verhofstad MHJ. Management of critical-sized bone defects in the treatment of fracture-related infection: a systematic review and pooled analysis. Arch Orthop Trauma Surg 2021; 141:1215-1230. [PMID: 32860565 PMCID: PMC8215045 DOI: 10.1007/s00402-020-03525-0] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/14/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE This systematic review determined the reported treatment strategies, their individual success rates, and other outcome parameters in the management of critical-sized bone defects in fracture-related infection (FRI) patients between 1990 and 2018. METHODS A systematic literature search on treatment and outcome of critical-sized bone defects in FRI was performed. Treatment strategies identified were, autologous cancellous grafts, autologous cancellous grafts combined with local antibiotics, the induced membrane technique, vascularized grafts, Ilizarov bone transport, and bone transport combined with local antibiotics. Outcomes were bone healing and infection eradication after primary surgical protocol and recurrence of FRI and amputations at the end of study period. RESULTS Fifty studies were included, describing 1530 patients, the tibia was affected in 82%. Mean age was 40 years (range 6-80), with predominantly male subjects (79%). Mean duration of infection was 17 months (range 1-624) and mean follow-up 51 months (range 6-126). After initial protocolized treatment, FRI was cured in 83% (95% CI 79-87) of all cases, increasing to 94% (95% CI 92-96) at the end of each individual study. Recurrence of infection was seen in 8% (95% CI 6-11) and amputation in 3% (95% CI 2-3). Final outcomes overlapped across treatment strategies. CONCLUSION Results should be interpreted with caution due to the retrospective and observational design of most studies, the lack of clear classification systems, incomplete data reports, potential underreporting of adverse outcomes, and heterogeneity in patient series. A consensus on classification, treatment protocols, and outcome is needed to improve reliability of future studies.
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Affiliation(s)
- H Bezstarosti
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - W J Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Louvain, Belgium
- Department of Development and Regeneration, KU Leuven, Louvain, Belgium
| | - E M M van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - L W Voskamp
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - K Kortram
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - M A McNally
- Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - L C Marais
- Department of Orthopaedics, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - M H J Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
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Abstract
Fracture-related infection (FRI) is common and often diagnosed late.Accurate diagnosis is the beginning of effective treatment.Diagnosis can be difficult, particularly when there are no outward signs of infection.The new FRI definition, together with clear protocols for nuclear imaging, microbiological culture and histological analysis, should allow much better study design and a clearer understanding of infected fractures.In recent years, there has been a new focus on defining FRI and avoiding non-specific, poorly targeted treatment. Previous studies on FRI have often failed to define infection precisely and so are of limited value. This review highlights the essential principles of making the diagnosis and how clinical signs, serum tests, imaging, microbiology, molecular biology and histology all contribute to the diagnostic pathway. Cite this article: EFORT Open Rev 2020;5:614-619. DOI: 10.1302/2058-5241.5.190072.
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Affiliation(s)
- Martin McNally
- The Oxford Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Geertje Govaert
- Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maria Dudareva
- The Oxford Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Mario Morgenstern
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland
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Metsemakers WJ, Morgenstern M, Senneville E, Borens O, Govaert GAM, Onsea J, Depypere M, Richards RG, Trampuz A, Verhofstad MHJ, Kates SL, Raschke M, McNally MA, Obremskey WT. General treatment principles for fracture-related infection: recommendations from an international expert group. Arch Orthop Trauma Surg 2020; 140:1013-1027. [PMID: 31659475 PMCID: PMC7351827 DOI: 10.1007/s00402-019-03287-4] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Indexed: 12/15/2022]
Abstract
Fracture-related infection (FRI) remains a challenging complication that creates a heavy burden for orthopaedic trauma patients, their families and treating physicians, as well as for healthcare systems. Standardization of the diagnosis of FRI has been poor, which made the undertaking and comparison of studies difficult. Recently, a consensus definition based on diagnostic criteria for FRI was published. As a well-established diagnosis is the first step in the treatment process of FRI, such a definition should not only improve the quality of published reports but also daily clinical practice. The FRI consensus group recently developed guidelines to standardize treatment pathways and outcome measures. At the center of these recommendations was the implementation of a multidisciplinary team (MDT) approach. If such a team is not available, it is recommended to refer complex cases to specialized centers where a MDT is available and physicians are experienced with the treatment of FRI. This should lead to appropriate use of antimicrobials and standardization of surgical strategies. Furthermore, an MDT could play an important role in host optimization. Overall two main surgical concepts are considered, based on the fact that fracture fixation devices primarily target fracture consolidation and can be removed after healing, in contrast to periprosthetic joint infection were the implant is permanent. The first concept consists of implant retention and the second consists of implant removal (healed fracture) or implant exchange (unhealed fracture). In both cases, deep tissue sampling for microbiological examination is mandatory. Key aspects of the surgical management of FRI are a thorough debridement, irrigation with normal saline, fracture stability, dead space management and adequate soft tissue coverage. The use of local antimicrobials needs to be strongly considered. In case of FRI, empiric broad-spectrum antibiotic therapy should be started after tissue sampling. Thereafter, this needs to be adapted according to culture results as soon as possible. Finally, a minimum follow-up of 12 months after cessation of therapy is recommended. Standardized patient outcome measures purely focusing on FRI are currently not available but the patient-reported outcomes measurement information system (PROMIS) seems to be the preferred tool to assess the patients' short and long-term outcome. This review summarizes the current general principles which should be considered during the whole treatment process of patients with FRI based on recommendations from the FRI Consensus Group.Level of evidence: Level V.
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Affiliation(s)
| | - Mario Morgenstern
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Eric Senneville
- Department of Infectious Diseases, Gustave Dron Hospital, University of Lille, Lille, France
| | - Olivier Borens
- Orthopedic Department of Septic Surgery, Orthopaedic-Trauma Unit, Department for the Musculoskeletal System, CHUV, Lausanne, Switzerland
| | - Geertje A M Govaert
- Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jolien Onsea
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Melissa Depypere
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | | | - Andrej Trampuz
- Center for Musculoskeletal Surgery, Berlin Institute of Health, Charité-Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Michael H J Verhofstad
- Department of Trauma Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Stephen L Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, USA
| | - Michael Raschke
- Department of Trauma Surgery, University Hospital of Münster, Münster, Germany
| | - Martin A McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - William T Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA
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50
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Metsemakers WJ. Nonsteroidal Anti-Inflammatory Drugs and Fracture Nonunion: An Ongoing Debate: Commentary on an article by Michael D. George, MD, MSCE, et al.: "Risk of Nonunion with Nonselective NSAIDs, COX-2 Inhibitors, and Opioids". J Bone Joint Surg Am 2020; 102:e82. [PMID: 32675680 DOI: 10.2106/jbjs.20.00836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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