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Wouthuyzen-Bakker M, Sebillotte M, Arvieux C, Fernandez-Sampedro M, Senneville E, Barbero JM, Lora-Tamayo J, Aboltins C, Trebse R, Salles MJ, Kramer TS, Ferrari M, Garcia-Cañete J, Benito N, Diaz-Brito V, del Toro MD, Scarborough M, Soriano A. How to Handle Concomitant Asymptomatic Prosthetic Joints During an Episode of Hematogenous Periprosthetic Joint Infection, a Multicenter Analysis. Clin Infect Dis 2021; 73:e3820-e3824. [PMID: 32813012 PMCID: PMC9187975 DOI: 10.1093/cid/ciaa1222] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Prosthetic joints are at risk of becoming infected during an episode of bacteremia, especially during Staphylocococcus aureus bacteremia. However, it is unclear how often asymptomatic periprosthetic joint infection (PJI) occurs, and whether additional diagnostics should be considered. METHODS In this multicenter study, we retrospectively analyzed a cohort of patients with a late acute (hematogenous) PJI between 2005-2015 who had concomitant prosthetic joints in situ. Patients without at least 1 year of follow-up were excluded. RESULTS We included 91 patients with a hematogenous PJI and 108 concomitant prosthetic joints. The incident PJI was most frequently caused by Staphylococcus aureus (43%), followed by streptococci (26%) and Gram-negative rods (18%). Of 108 concomitant prosthetic joints, 13 were symptomatic, of which 10 were subsequently diagnosed as a second PJI. Of the 95 asymptomatic prosthetic joints, 1 PJI developed during the follow-up period and was classified as a "missed" PJI at the time of bacteremia with S. aureus (1.1%). Infected prosthetic joints were younger than the noninfected ones in 67% of cases, and prosthetic knees were affected more often than prosthetic hips (78%). CONCLUSIONS During an episode of hematogenous PJI, concomitant asymptomatic prosthetic joints have a very low risk of being infected, and additional diagnostic work-up for these joints is not necessary.
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Affiliation(s)
- Marjan Wouthuyzen-Bakker
- Correspondence: M. Wouthuyzen-Bakker, Infectious Disease Specialist, University Medical Center Groningen, Department of Medical Microbiology and Infection Prevention, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands ()
| | - Marine Sebillotte
- Department of Infectious Diseases and Intensive Care Medicine, Rennes University Hospital, Rennes, France
| | - Cédric Arvieux
- Department of Infectious Diseases and Intensive Care Medicine, Rennes University Hospital, Rennes, France
- Great West Reference centers for Complex Bone and Joint Infections (CRIOGO), Rennes, France
| | - Marta Fernandez-Sampedro
- Service of Infectious Diseases, Hospital Universitario Marqués de Valdecilla, University of Cantabria, Instituto de investigación sanitaria Valdecilla (IDIVAL), Santander, Spain
| | - Eric Senneville
- Department of Infectious Diseases, Lille, University Hospital Gustave Dron Hospital, Tourcoing, France
| | - José Maria Barbero
- Department of Internal Medicine. Hospital Universitario Principe de Asturias, Madrid, Spain
| | - Jaime Lora-Tamayo
- Department of Internal Medicine. Hospital Universitario 12 de Octubre. Instituto de Investigación i+12. Madrid, Spain
| | - Craig Aboltins
- The Department of Infectious Diseases, Northern Health, Melbourne, Australia
- The University of Melbourne, Northern Clinical School, Melbourne, Australia
| | - Rihard Trebse
- Service for Bone Infections, Valdoltra Orthopaedic Hospital, the Faculty of Medicine, University of Ljublijana, Ankaran, Slovenia
| | - Mauro José Salles
- Santa Casa de São Paulo School of Medical Sciences and Musculoskeletal infection group, Federal University of São Paulo, Brasil
| | - Tobias Siegfried Kramer
- Institute for hygiene and environmental medicine Charité-Universitätsmedizin Berlin, Germany
- Evangelisches Waldkrankenhaus Spandau, BerlinGermany
| | - Matteo Ferrari
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Humanitas Research Hospital, Milan, Italy
| | - Joaquín Garcia-Cañete
- Department of Internal Medicine-Emergency, Instituto de Investigación Sanitaria (IIS)-Fundación Jiménez Díaz, Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Natividad Benito
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Institut d’Investigació Biomèdica Sant Pau, Barcelona, Spain
- Department of Medicine. Universitat Autònoma de Barcelona, Spain
| | - Vicens Diaz-Brito
- Infectious Diseases Unit, Parc Sanitari Sant Joan de Deu, Sant Boi, Barcelona, Spain
| | - Maria Dolores del Toro
- Unidad Clínica de Enfermedades Infecciosa y Microbiología. Universidad de Sevilla. Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain
| | - Matthew Scarborough
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, England
| | - Alex Soriano
- Service of Infectious Diseases, Hospital Clínic, University of Barcelona, Barcelona, Spain
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Wouthuyzen-Bakker M, Sebillotte M, Huotari K, Escudero Sánchez R, Benavent E, Parvizi J, Fernandez-Sampedro M, Barbero JM, Garcia-Cañete J, Trebse R, Del Toro M, Diaz-Brito V, Sanchez M, Scarborough M, Soriano A. Lower Success Rate of Débridement and Implant Retention in Late Acute versus Early Acute Periprosthetic Joint Infection Caused by Staphylococcus spp. Results from a Matched Cohort Study. Clin Orthop Relat Res 2020; 478:1348-1355. [PMID: 32106134 PMCID: PMC7319375 DOI: 10.1097/corr.0000000000001171] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [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: 09/07/2019] [Accepted: 01/30/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgical débridement, antibiotics and implant retention (DAIR) is currently recommended by international guidelines for both early acute (postsurgical) and late acute (hematogenous) periprosthetic joint infections (PJIs). However, due to a different pathogenesis of infection, a different treatment strategy may be needed. QUESTIONS/PURPOSES (1) Compared with early acute PJIs, are late acute PJIs associated with a higher risk of DAIR failure? (2) When stratified by microorganism, is the higher risk of failure in late acute PJI associated with Staphylocococcus aureus infection? (3) When analyzing patients with S. aureus infection, what factors are independently associated with DAIR failure? METHODS In this multicenter observational study, early acute and late acute PJIs treated with DAIR were retrospectively evaluated and matched according to treating center, year of diagnosis, and infection-causing microorganism. If multiple matches were available, the early acute PJI diagnosed closest to the late acute PJI was selected. A total of 132 pairs were included. Treatment success was defined as a retained implant during follow-up without the need for antibiotic suppressive therapy. RESULTS Late acute PJIs had a lower treatment success (46% [60 of 132]) compared with early acute PJIs (76% [100 of 132]), OR 3.9 [95% CI 2.3 to 6.6]; p < 0.001), but the lower treatment success of late acute PJIs was only observed when caused by Staphylococcus spp (S. aureus: 34% versus 75%; p < 0.001; coagulase-negative staphylococci: 46% versus 88%; p = 0.013, respectively). On multivariable analysis, late acute PJI was the only independent factor associated with an unsuccessful DAIR when caused by S. aureus (OR 4.52 [95% CI 1.79 to 11.41]; p < 0.001). CONCLUSIONS Although DAIR seems to be a successful therapeutic strategy in the management of early acute PJI, its use in late acute PJI should be reconsidered when caused by Staphylococcus spp. Our results advocate the importance of isolating the causative microorganism before surgery. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Marjan Wouthuyzen-Bakker
- M. Wouthuyzen-Bakker, Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Marine Sebillotte
- M. Sebillotte, Department of Infectious Diseases and Intensive Care Medicine, Rennes University Hospital, Rennes, France
| | - Kaisa Huotari
- K. Huotari, Inflammation center, Infectious Diseases, Peijas Hospital, Helsinki University Hospital and University of Helsinki, Finland
| | - Rosa Escudero Sánchez
- R. Escudero-Sánchez, Servicio de Enfermedades Infecciosas, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Eva Benavent
- E. Benavent, Infectious Disease Service, IDIBELL-Hospital Universitari Bellvitge, Barcelona, Spain
| | - Javad Parvizi
- J. Parvizi, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Marta Fernandez-Sampedro
- M. Fernandez-Sampedro, Infectious Diseases Unit, Department of Medicine, Hospital Universitario Marques de Valdecilla-IDIVAL, Cantabria, Spain
| | - José Maria Barbero
- J. M. Barbero, Department of Internal Medicine, Hospital Universitario Principe de Asturias, Madrid, Spain
| | - Joaquín Garcia-Cañete
- J. Garcia-Cañete, Department of Internal Medicine-Emergency, IIS-Fundación Jiménez Díaz, UAM, Madrid, Spain
| | - Rihard Trebse
- R. Trebse, Service for Bone Infections, Valdoltra Orthopaedic Hospital, Ankaran, Slovenia
| | - Maria Del Toro
- M. Del Toro, Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Universidad de Sevilla, Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain
| | - Vicens Diaz-Brito
- V. Diaz-Brito, Infectious Diseases Unit, Parc Sanitari Sant Joan de Deu, Sant Boi, Barcelona, Spain
| | - Marisa Sanchez
- M. Sanchez, Infectious Diseases Section, Internal Medicine Service, Hospital Italiano de Buenos Aires, Argentina
| | - Matthew Scarborough
- M. Scarborough, Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Alex Soriano
- A. Soriano, Service of Infectious Diseases, Hospital Clínic, University of Barcelona, Barcelona, Spain
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Wouthuyzen-Bakker M, Sebillotte M, Lomas J, Taylor A, Palomares EB, Murillo O, Parvizi J, Shohat N, Reinoso JC, Sánchez RE, Fernandez-Sampedro M, Senneville E, Huotari K, Barbero JM, Garcia-Cañete J, Lora-Tamayo J, Ferrari MC, Vaznaisiene D, Yusuf E, Aboltins C, Trebse R, Salles MJ, Benito N, Vila A, Toro MDD, Kramer TS, Petersdorf S, Diaz-Brito V, Tufan ZK, Sanchez M, Arvieux C, Soriano A. Clinical outcome and risk factors for failure in late acute prosthetic joint infections treated with debridement and implant retention. J Infect 2019; 78:40-47. [PMID: 30092305 DOI: 10.1016/j.jinf.2018.07.014] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [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: 12/21/2017] [Revised: 07/05/2018] [Accepted: 07/19/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Debridement, antibiotics and implant retention (DAIR) is the recommended treatment for all acute prosthetic joint infections (PJI), but its efficacy in patients with late acute (LA) PJI is not well described. METHODS Patients diagnosed with LA PJI between 2005 and 2015 were retrospectively evaluated. LA PJI was defined as the development of acute symptoms (≤ 3 weeks) occurring ≥ 3 months after arthroplasty. Failure was defined as: (i) the need for implant removal, (ii) infection related death, (iii) the need for suppressive antibiotic therapy and/or (iv) relapse or reinfection during follow-up. RESULTS 340 patients from 27 centers were included. The overall failure rate was 45.0% (153/340). Failure was dominated by Staphylococcus aureus PJI (54.7%, 76/139). Significant independent preoperative risk factors for failure according to the multivariate analysis were: fracture as indication for the prosthesis (odds ratio (OR) 5.4), rheumatoid arthritis (OR 5.1), age above 80 years (OR 2.6), male gender (OR 2.0) and C-reactive protein > 150 mg/L (OR 2.0). Exchanging the mobile components during DAIR was the strongest predictor for treatment success (OR 0.35). CONCLUSION LA PJIs have a high failure rate. Treatment strategies should be individualized according to patients' age, comorbidity, clinical presentation and microorganism causing the infection.
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Affiliation(s)
- Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
| | - Marine Sebillotte
- Department of Infectious Diseases and IntensiveCare Medicine, Rennes University Hospital, Rennes, France
| | - Jose Lomas
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Adrian Taylor
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | | | - Oscar Murillo
- Infectious Disease Service, IDIBELL-Hospital Universitari Bellvitge, Barcelona, Spain
| | - Javad Parvizi
- Rothman Institute at Thomas Jefferson University Hospital, Philidelphia, United States
| | - Noam Shohat
- Rothman Institute at Thomas Jefferson University Hospital, Philidelphia, United States; Department of Orthopaedic Surgery, Tel Aviv University, Tel Aviv, Israel
| | - Javier Cobo Reinoso
- Servicio de Enfermedades Infecciosas, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Rosa Escudero Sánchez
- Servicio de Enfermedades Infecciosas, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Marta Fernandez-Sampedro
- Infectious Diseases Unit, Department of Medicine, Hospital Universitario Marques de Valdecilla-IDIVAL, Cantabria, Spain
| | - Eric Senneville
- Department of Infectious Diseases, University Hospital Gustave Dron Hospital, Tourcoing, France
| | - Kaisa Huotari
- Inflammation center, Infectious Diseases, Peijas Hospital, Helsinki University Hospital and University of Helsinki, Finland
| | - José Maria Barbero
- Department of Internal Medicine, Hospital Universitario Principe de Asturias, Madrid, Spain
| | - Joaquín Garcia-Cañete
- Department of Internal Medicine-Emergency, IIS-Fundación Jiménez Díaz, UAM, Av. Reyes Católicos 2, 28040 Madrid, Spain
| | - Jaime Lora-Tamayo
- Department of Internal Medicine. Hospital Universitario 12 de Octubre. Instituto de Investigación i+12, Madrid, Spain
| | - Matteo Carlo Ferrari
- Department of Prosthetic Joint Replacement and Rehabilitation Center, Humanitas Research Hospital and Humanitas University, Milan, Italy
| | - Danguole Vaznaisiene
- Department of Infectious Diseases, Medical Academy, Lithuanian University of Health Sciences, Kaunas Clinical Hospital, Kaunas, Lithuania
| | - Erlangga Yusuf
- Department of Microbiology, Antwerp University Hospital (UZA), University of Antwerp, Edegem, Belgium
| | - Craig Aboltins
- The Department of Infectious Diseases, Northern Health, Melbourne, Australia; The University of Melbourne, Northern Clinical School, Melbourne, Australia
| | - Rihard Trebse
- Service for Bone Infections, Valdoltra Orthopaedic Hospital, Ankaran, Slovenia
| | - Mauro José Salles
- Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brasil
| | - Natividad Benito
- Infectious Diseases Unit, Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Andrea Vila
- Servicio de Infectología, Hospital Italiano de Mendoza, Mendoza, Argentina
| | - Maria Dolores Del Toro
- Unidad Clínica de Enfermedades Infecciosa y Microbiología, Universidad de Sevilla, Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain
| | - Tobias Siegfried Kramer
- Nationales Referenzzentrum für Surveillance von nosokomialen Infektionen am Institut für Hygiene und Umweltmedizin Charité-Universitätsmedizin, Berlin, Germany; LADR, GmbH MVZ, Neuruppin, Germany
| | - Sabine Petersdorf
- Institute of Medical Microbiology and Hospital Hygiene University Hospital, Heinrich-Heine-University. Düsseldorf, Germany
| | - Vicens Diaz-Brito
- Infectious Diseases Unit, Parc Sanitari Sant Joan de Deu, Sant Boi, Barcelona, Spain
| | - Zeliha Kocak Tufan
- Infectious Diseases and Clinical Microbiology Department, Ankara Yildirim Beyazit University, Ataturk Training & Research Hospital, Ankara, Turkey
| | - Marisa Sanchez
- Infectious Diseases Section, Internal Medicine Service, Hospital Italiano de Buenos Aires, Argentina
| | - Cédric Arvieux
- Department of Infectious Diseases and IntensiveCare Medicine, Rennes University Hospital, Rennes, France; Great West Reference centers for Complex Bone and Joint Infections (CRIOGO), France
| | - Alex Soriano
- Service of Infectious Diseases, Hospital Clínic, University of Barcelona, Barcelona, Spain
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Prieto-Borja L, Rodriguez-Sevilla G, Auñon A, Pérez-Jorge C, Sandoval E, Garcia-Cañete J, Gadea I, Fernandez-Roblas R, Blanco A, Esteban J. Evaluation of a commercial multiplex PCR (Unyvero i60 ®) designed for the diagnosis of bone and joint infections using prosthetic-joint sonication. Enferm Infecc Microbiol Clin 2016; 35:236-242. [PMID: 27769681 DOI: 10.1016/j.eimc.2016.09.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [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: 03/20/2016] [Revised: 09/04/2016] [Accepted: 09/13/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND The development of sonication protocols over the last few years has improved the sensitivity of conventional cultures for the diagnosis of prosthetic-joint infection (PJI). However, the development of a new, specifically designed kit for the molecular diagnosis of PJI could provide a major improvement in this field. METHODS Prostheses retrieved from patients who underwent implant removal from May 2014 to May 2015 were sent for culture, and processed according to a previously defined protocol that included sonication. Furthermore, 180 microlitres of sonication fluid were used to carry out the multiplex PCR test (Unyvero i60 system®). A comparison of the sensitivity, specificity, positive (PPV) and negative (NPV) predictive value, was performed. The study was approved by the Clinical Research Ethics Committee. RESULTS The analysis included 88 prostheses from 68 patients (1.29 prostheses/patient). The type of prostheses studied were knee (n=55), total hip (n=26), partial hip (n=5), and shoulder (n=2). Twenty-nine patients were diagnosed with a PJI (15 delayed, 12 acute, and 2 haematogenous infections). In 24 cases, the result of the PCR was positive, all but 1 corresponding to patients with clinical criteria of PJI. Nine resistance mechanisms were detected from 5 samples. The Unyvero i60 system® showed slightly better results than traditional culture in terms of specificity and PPV. CONCLUSIONS The Unyvero i60 system® may play a role in rapid diagnosis of PJI, due to its high specificity and PPV. However, despite these results, cultures have to be performed to detect organisms not detected by the system.
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Affiliation(s)
- Laura Prieto-Borja
- Department of Clinical Microbiology, IIS-Fundación Jiménez Díaz, UAM, Av. Reyes Católicos 2, 28040 Madrid, Spain
| | - Graciela Rodriguez-Sevilla
- Department of Clinical Microbiology, IIS-Fundación Jiménez Díaz, UAM, Av. Reyes Católicos 2, 28040 Madrid, Spain
| | - Alvaro Auñon
- Department of Orthopaedic Surgery, IIS-Fundación Jiménez Díaz, UAM, Av. Reyes Católicos 2, 28040 Madrid, Spain
| | - Concepción Pérez-Jorge
- Department of Clinical Microbiology, IIS-Fundación Jiménez Díaz, UAM, Av. Reyes Católicos 2, 28040 Madrid, Spain
| | - Enrique Sandoval
- Department of Orthopaedic Surgery, IIS-Fundación Jiménez Díaz, UAM, Av. Reyes Católicos 2, 28040 Madrid, Spain
| | - Joaquín Garcia-Cañete
- Department of Internal Medicine-Emergency, IIS-Fundación Jiménez Díaz, UAM, Av. Reyes Católicos 2, 28040 Madrid, Spain
| | - Ignacio Gadea
- Department of Clinical Microbiology, IIS-Fundación Jiménez Díaz, UAM, Av. Reyes Católicos 2, 28040 Madrid, Spain
| | - Ricardo Fernandez-Roblas
- Department of Clinical Microbiology, IIS-Fundación Jiménez Díaz, UAM, Av. Reyes Católicos 2, 28040 Madrid, Spain
| | - Antonio Blanco
- Department of Internal Medicine-Emergency, IIS-Fundación Jiménez Díaz, UAM, Av. Reyes Católicos 2, 28040 Madrid, Spain
| | - Jaime Esteban
- Department of Clinical Microbiology, IIS-Fundación Jiménez Díaz, UAM, Av. Reyes Católicos 2, 28040 Madrid, Spain.
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5
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Esteban J, Alvarez-Alvarez B, Blanco A, Fernández-Roblas R, Gadea I, Garcia-Cañete J, Sandoval E, Valdazo M. Prolonged incubation time does not increase sensitivity for the diagnosis of implant-related infection using samples prepared by sonication of the implants. Bone Joint J 2013; 95-B:1001-6. [DOI: 10.1302/0301-620x.95b7.31174] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [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] [Indexed: 11/05/2022]
Abstract
We have designed a prospective study to evaluate the usefulness of prolonged incubation of cultures from sonicated orthopaedic implants. During the study period 124 implants from 113 patients were processed (22 osteosynthetic implants, 46 hip prostheses, 54 knee prostheses, and two shoulder prostheses). Of these, 70 patients had clinical infection; 32 had received antibiotics at least seven days before removal of the implant. A total of 54 patients had sonicated samples that produced positive cultures (including four patients without infection). All of them were positive in the first seven days of incubation. No differences were found regarding previous antibiotic treatment when analysing colony counts or days of incubation in the case of a positive result. In our experience, extending incubation of the samples to 14 days does not add more positive results for sonicated orthopaedic implants (hip and knee prosthesis and osteosynthesis implants) compared with a conventional seven-day incubation period. Cite this article: Bone Joint J 2013;95-B:1001–6.
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Affiliation(s)
- J. Esteban
- IIS-Fundacion Jimenez Diaz, Department
of Clinical Microbiology, Av. Reyes Catolicos 2, 28040
Madrid, Spain
| | - B. Alvarez-Alvarez
- IIS-Fundacion Jimenez Diaz, Department
of Emergency Medicine, Av. Reyes Catolicos 2, 28040
Madrid, Spain
| | - A. Blanco
- IIS-Fundacion Jimenez Diaz, Department
of Emergency Medicine, Av. Reyes Catolicos 2, 28040
Madrid, Spain
| | - R. Fernández-Roblas
- IIS-Fundacion Jimenez Diaz, Department
of Clinical Microbiology, Av. Reyes Catolicos 2, 28040
Madrid, Spain
| | - I. Gadea
- IIS-Fundacion Jimenez Diaz, Department
of Clinical Microbiology, Av. Reyes Catolicos 2, 28040
Madrid, Spain
| | - J. Garcia-Cañete
- IIS-Fundacion Jimenez Diaz, Department
of Emergency Medicine, Av. Reyes Catolicos 2, 28040
Madrid, Spain
| | - E. Sandoval
- IIS-Fundacion Jimenez Diaz, Department
of Orthopaedic Surgery, Av. Reyes Catolicos 2, 28040
Madrid, Spain
| | - M. Valdazo
- IIS-Fundacion Jimenez Diaz, Department
of Orthopaedic Surgery, Av. Reyes Catolicos 2, 28040
Madrid, Spain
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