ABSTRACT
PURPOSE: Unexpected positive cultures are defined as a single positive culture in intraoperative samples taken during revision surgery after prosthetic joint infection was preoperatively ruled out. This study aims to determine the prevalence of unexpected positive cultures (UPC) in revision total knee arthroplasty (TKA) after unicompartmental knee arthroplasty (UKA). As a secondary objective, this study aims to compare the re-intervention rate in this specific group, between UPC and non-UPC patients. The hypothesis is that the UPC prevalence in patients who undergo a revision TKA after UKA is not higher than in other TKA revision cases and this does not increase the risk of re-intervention. METHODS: This is a retrospective study where all patients who underwent a UKA revision from January 2016 to February 2023 in a high-volume arthroplasty centre, were analyzed. Unexpected positive culture prevalence in this group of patients was obtained. RESULTS: During the included period, 270 UKA revision surgeries were performed. Eight cases had at least two positive cultures and were therefore excluded. The final analysis included 262 patients. Of these, 8 (3.05%) patients presented UPCs and the isolated microorganisms were low-virulence organisms. None of the UPC patients received any treatment. No statistical differences were found between UPC and non-UPC groups in the analyzed variables. CONCLUSION: The prevalence of unexpected positive cultures in patients following revision of unicompartmental knee arthroplasty is lower than in patients who undergo a revision of total knee arthroplasty. In UKA patients a UPC does not seem to increase the risk of a re-intervention, so it can be safely ignored if ICM criteria are not met.
Subject(s)
Arthroplasty, Replacement, Knee , Knee Prosthesis , Prosthesis-Related Infections , Reoperation , Humans , Arthroplasty, Replacement, Knee/adverse effects , Arthroplasty, Replacement, Knee/methods , Reoperation/statistics & numerical data , Retrospective Studies , Prosthesis-Related Infections/epidemiology , Prosthesis-Related Infections/microbiology , Prosthesis-Related Infections/diagnosis , Prosthesis-Related Infections/etiology , Prosthesis-Related Infections/surgery , Male , Female , Aged , Middle Aged , Knee Prosthesis/adverse effects , Knee Prosthesis/microbiology , Prevalence , Aged, 80 and overABSTRACT
OBJECTIVES: This study aimed to investigate whether adding tissue samples directly into thioglycolate (TG) broth yielded a greater number of anaerobic organisms than freshly sampled tissue in suspected hip and knee prosthetic joint infections (PJIs). PATIENTS AND METHODS: Between January 2017 and December 2020, a total of 90 patients (46 males, 44 females; median age: 71.7 years; range, 50.8 and 87.8 years) who underwent revision hip or knee arthroplasty were included. Intraoperative samples were taken, with five placed in TG broth and five in standard containers (PC) with subsequent aerobic and anaerobic culturing conducted. Demographic and baseline data of the patients were recorded. The primary outcome was positive bacterial growth from a PJI specimen inoculated directly into TG broth at the time of collection or standard PJI specimen processing. Secondary outcomes investigated were the presence of Cutibacterium acnes (C. acnes) and the curative success of revision procedure. RESULTS: A total of 900 samples (450 PC and 450 TG) were taken from 90 revision arthroplasty patients (47 knees and 43 hips). There was no statistically significant difference in the number of positive bacterial growth samples between TG broth and standard processing (p=0.742). This was consistent with subgroup analysis analyzing C. acnes (p=0.666). CONCLUSION: In hip and knee arthroplasty, there is no benefit in substituting or adding TG broth as a culture medium to better identify both general bacterial species and C. acnes infections specifically. However, the use of TG may be useful in confirming a true positive result for infection.
Subject(s)
Arthroplasty, Replacement, Hip , Arthroplasty, Replacement, Knee , Prosthesis-Related Infections , Thioglycolates , Humans , Prosthesis-Related Infections/diagnosis , Prosthesis-Related Infections/microbiology , Prosthesis-Related Infections/drug therapy , Female , Male , Aged , Middle Aged , Aged, 80 and over , Arthroplasty, Replacement, Knee/adverse effects , Arthroplasty, Replacement, Hip/adverse effects , Thioglycolates/pharmacology , Knee Prosthesis/adverse effects , Knee Prosthesis/microbiology , Culture Media/chemistry , Culture Media/pharmacology , Reoperation , Hip Prosthesis/adverse effects , Hip Prosthesis/microbiology , Specimen Handling/methods , Retrospective StudiesABSTRACT
BACKGROUND: Chronic periprosthetic joint infection (PJI) is a major complication of total joint arthroplasty. The underlying pathogenesis often involves the formation of bacterial biofilm that protects the pathogen from both host immune responses and antibiotics. The gold standard treatment requires implant removal, a procedure that carries associated morbidity and mortality risks. Strategies to preserve the implant while treating PJI are desperately needed. Our group has developed an anti-biofilm treatment, PhotothermAA gel, which has shown complete eradication of 2-week-old mature biofilm in vitro. In this study, we tested the anti-biofilm efficacy and safety of PhotothermAA in vivo when combined with debridement, antibiotics and implant retention (DAIR) in a rabbit model of knee PJI. METHODS: New Zealand white rabbits (n = 21) underwent knee joint arthrotomy, titanium tibial implant insertion, and inoculation with Xen36 (bioluminescent Staphylococcus aureus) after capsule closure. At 2 weeks, rabbits underwent sham surgery (n = 6), DAIR (n = 6), or PhotothermAA with DAIR (n = 9) and were sacrificed 2 weeks later to measure implant biofilm burden, soft-tissue infection, and tissue necrosis. RESULTS: The combination of anti-biofilm PhotothermAA with DAIR significantly decreased implant biofilm coverage via scanning electron microscopy compared to DAIR alone (1.8 versus 81.0%; P < .0001). Periprosthetic soft-tissue cultures were significantly decreased in the PhotothermAA with DAIR treatment group (log reduction: Sham 1.6, DAIR 2.0, combination 5.6; P < .0001). Treatment-associated necrosis was absent via gross histology of tissue adjacent to the treatment area (P = .715). CONCLUSIONS: The addition of an anti-biofilm solution like PhotothermAA as a supplement to current treatments that allow implant retention may prove useful in PJI treatment.
Subject(s)
Anti-Bacterial Agents , Arthroplasty, Replacement, Knee , Biofilms , Debridement , Disease Models, Animal , Knee Prosthesis , Prosthesis-Related Infections , Staphylococcal Infections , Animals , Rabbits , Biofilms/drug effects , Prosthesis-Related Infections/microbiology , Prosthesis-Related Infections/prevention & control , Debridement/methods , Anti-Bacterial Agents/therapeutic use , Staphylococcal Infections/prevention & control , Knee Prosthesis/adverse effects , Knee Prosthesis/microbiology , Arthroplasty, Replacement, Knee/adverse effects , Awards and Prizes , Staphylococcus aureus/drug effects , Staphylococcus aureus/physiology , Knee Joint/surgery , Knee Joint/microbiology , Combined Modality Therapy , Prosthesis Retention , GelsABSTRACT
INTRODUCTION: The onset of prosthetic joint infections (PJIs) is characterized by early onset defined as within 90 days of the procedure, delayed onset defined as within 3 to 12 months, and late onset defined as over 12 months. In only a scant number of case reports, Mycobacterium flavescens associated infections are typically found in sputum cultures and associated with various forms of penetrating joint traumas, particularly post-surgical interventions. Due to its rarity in presentation among cases of PJIs, we have presented a case of PJI caused by Mycobacterium flavescens. CASE PRESENTATION: We have, herein, reported a case of a 70-year-old male presenting with stabbing left knee pain over the past several months along with accompanying erythema and swelling with the presence of purulent discharge. Outpatient cultures have shown the growth of Mycobacterium flavescent; subsequently, the patient underwent a 2-stage revision arthroplasty and was treated with a three-drug regimen and implant 5 months later. Although being an atypical cause of PJIs, we emphasize the importance of considering NTM as a differential for immunocompromised patients, especially those with prior surgical intervention. DISCUSSION: Mycobacterium spp. related PJIs manifest clinical features similar to other bacteriacausing PJIs, such as warm, indurated edema at the surgical site resulting in wound dehiscence and joint effusion. Diagnosis of Mycobacterium spp. related PJIs includes history and physical examination findings, serum inflammatory markers, synovial fluid analysis, and culture. Concurrently with surgical interventions, utilization of antimicrobial agents provides additional control in Mycobacterium- related PJI. Mycobacterium flavescens should be included among other NTMs as a possible cause of PJIs.
Subject(s)
Anti-Bacterial Agents , Mycobacterium Infections, Nontuberculous , Prosthesis-Related Infections , Humans , Male , Aged , Prosthesis-Related Infections/microbiology , Prosthesis-Related Infections/drug therapy , Prosthesis-Related Infections/diagnosis , Mycobacterium Infections, Nontuberculous/diagnosis , Mycobacterium Infections, Nontuberculous/drug therapy , Mycobacterium Infections, Nontuberculous/microbiology , Anti-Bacterial Agents/therapeutic use , Arthroplasty, Replacement, Knee/adverse effects , Knee Prosthesis/adverse effects , Knee Prosthesis/microbiology , Reoperation , Knee Joint/surgery , Knee Joint/microbiology , Nontuberculous Mycobacteria/isolation & purificationABSTRACT
BACKGROUND: The purpose of this study was to determine the prevalence of unexpected positive cultures noted at the time of revision surgery for periprosthetic fracture (PPF) after total hip or knee arthroplasty. Moreover, we evaluated whether this finding should be considered clinically significant and what type of treatment, if any, was required. METHODS: This was a single-center retrospective review of 270 patients undergoing surgery for PPFs from December 2010 to December 2021. Exclusion criteria included: open fractures; history of infection at fractured joint; non-operatively treated patients; and intraoperative fractures. The primary end point was the prevalence of unexpected positive cultures noted at the time of revision surgery. This was defined as one or more positive cultures in a PPF that the surgeon had preoperatively classified as aseptic according to the 2018 International Consensus Meeting. Data collection included patient demographics, medical histories, preoperative investigations, postoperative microbiology, and treatment. RESULTS: During the study period, 159 patients were admitted with PPFs of the hip and 61 with PPFs of the knee. The mean age was 70 years (range, 32 to 93 years). Unexpected positive cultures were diagnosed postoperatively in 15 patients (6.8%; 10 hips, 5 knees). The most prevalent organism was Staphylococcus epidermidis (35.0%). Of those 15 patients, 6 required a surgical revision for infection. None of the patient-related risk factors were found to be associated with an increased risk of unexpected positive cultures. The comparison between infected and noninfected patients showed a significant association between preoperative C-reactive protein >10 mg/mL (P = .04), loose implant (P = .07), and infection. CONCLUSIONS: The prevalence of unexpected positive cultures was 6.8% in our study cohort. Although surgical treatment may be required, the majority of patients seem to require no treatment. Larger series are required to investigate the clinical importance of this rare finding. LEVEL OF EVIDENCE: III.
Subject(s)
Arthroplasty, Replacement, Hip , Arthroplasty, Replacement, Knee , Periprosthetic Fractures , Prosthesis-Related Infections , Reoperation , Humans , Periprosthetic Fractures/surgery , Periprosthetic Fractures/epidemiology , Periprosthetic Fractures/etiology , Aged , Middle Aged , Female , Retrospective Studies , Male , Arthroplasty, Replacement, Knee/adverse effects , Aged, 80 and over , Reoperation/statistics & numerical data , Arthroplasty, Replacement, Hip/adverse effects , Prosthesis-Related Infections/microbiology , Prosthesis-Related Infections/etiology , Prosthesis-Related Infections/epidemiology , Adult , Staphylococcus epidermidis/isolation & purification , Knee Prosthesis/adverse effects , Knee Prosthesis/microbiology , PrevalenceABSTRACT
BACKGROUND: Prosthetic joint infection (PJI) is the leading cause of revision following total knee arthroplasty (TKA). Prior to microorganism identification, the choice of the correct empiric antibiotics is critical to treatment success. This study aims to 1) compare the microorganism and resistance profile in early and late PJIs; 2) recommend appropriate empiric antibiotics. METHODS: A multicentre retrospective review was performed over a 15-year period. First episode PJIs were classified by both the Tsukayama Classification and Auckland Classification. For each PJI case, the causative organism and antibiotic sensitivity were recorded. RESULTS: Of eligible patients, 232 culture-positive PJI cases were included. Using either classification system, early PJIs (<4 weeks or <1 year since primary) were significantly more likely to be resistant and polymicrobial. The predominant organisms were coagulase-negative Staphylococci in early PJIs while Staphylococcus aureus was the most common in late PJIs. The distribution of gram-negative cases was higher in early Class-A than late Class-C PJIs (25% versus 6%, P = .004). Vancomycin provided significantly superior coverage when compared to Flucloxacillin for early infections, and addition of a gram-negative agent achieved coverage over 90% using both classification systems. CONCLUSION: Based on the microbiological pattern in Tsukayama criteria, Vancomycin with the consideration of Gram-negative agent should be considered for Class-A infections given the high proportion of resistant and polymicrobial cases. For Class-C infections, Cephazolin or Flucloxacillin is likely sufficient. We recommend antibiotics to be withheld in Class-B infections until cultures and sensitivities are known.
Subject(s)
Arthritis, Infectious , Arthroplasty, Replacement, Knee , Hip Prosthesis , Knee Prosthesis , Prosthesis-Related Infections , Anti-Bacterial Agents/therapeutic use , Arthritis, Infectious/microbiology , Arthroplasty, Replacement, Knee/adverse effects , Floxacillin , Hip Prosthesis/microbiology , Humans , Knee Prosthesis/adverse effects , Knee Prosthesis/microbiology , Prosthesis-Related Infections/drug therapy , Prosthesis-Related Infections/microbiology , Retrospective Studies , VancomycinABSTRACT
BACKGROUND: Intra-wound vancomycin powder (VP) has been used in clinical practice to prevent periprosthetic joint infection (PJI) after primary knee/hip arthroplasty. The role of intra-wound VP in the setting of debridement and implant exchange after PJI remains undefined. This study aimed to explore the efficacy and safety of intra-wound VP in the control of methicillin-resistant S. aureus (MRSA) infection after debridement and implant exchange. METHODS: PJI modeling by knee prosthesis implantation and MRSA inoculation, debridement and implant exchange were performed in Wistar rats successively to mimic the one-stage exchange arthroplasty of PJI patients. Two weeks of systemic vancomycin (SV) or/and intraoperative intra-wound VP of single dosage were applied after revision surgery. RESULTS: No post-surgery deaths, incision complications and signs of drug toxicity were observed. The microbial counts of SV or intra-wound VP group were significantly reduced compared with the control group, while bacteria were still detected on the bone, soft-tissue and prosthesis. The elimination of bacterial counts, along with improvement of tissue inflammation and serum inflammatory markers, were observed in the rats with SV plus intra-wound VP. Serum levels of vancomycin in all groups were lower than that of causing nephrotoxicity, while no statistic difference was observed in the serum biochemical marker among the groups. CONCLUSIONS: Intra-wound VP is effective after debridement and implant exchange in our current rat PJI model. Neither SV nor intra-wound VP alone could eradicate the bacteria within a two-weeks treatment course, while SV plus intra-wound VP could eliminate the MRSA infection, without notable hepatic or renal toxicity and any incision complications.
Subject(s)
Arthroplasty, Replacement, Knee , Debridement , Prosthesis-Related Infections/prevention & control , Vancomycin/administration & dosage , Animals , Anti-Bacterial Agents/administration & dosage , Arthroplasty, Replacement, Knee/adverse effects , Debridement/adverse effects , Disease Models, Animal , Knee Prosthesis/adverse effects , Knee Prosthesis/microbiology , Methicillin-Resistant Staphylococcus aureus/drug effects , Powders , Prosthesis-Related Infections/etiology , Rats , Rats, Wistar , Staphylococcal Infections/etiology , Staphylococcal Infections/prevention & control , Treatment Outcome , Vancomycin/pharmacologyABSTRACT
Rapid synovial fluid-induced aggregation of Staphylococcus aureus is currently being investigated as an important factor in the establishment of periprosthetic joint infections (PJIs). Pathogenic advantages of aggregate formation have been well documented in vitro, including recalcitrance to antibiotics and protection from host immune defenses. The objective of the present work was to determine the strain dependency of synovial fluid-induced aggregation by measuring the degree of aggregation of 21 clinical S. aureus isolates cultured from either PJI or bloodstream infections using imaging and flow cytometry. Furthermore, by measuring attached bacterial biomass using a conventional crystal violet assay, we assessed whether there is a correlation between the aggregative phenotype and surface-associated biofilm formation. While all of the isolates were stimulated to aggregate upon exposure to bovine synovial fluid (BSF) and human serum (HS), the extent of aggregation was highly variable between individual strains. Interestingly, the PJI isolates aggregated significantly more upon BSF exposure than those isolated from bloodstream infections. While we were able to stimulate biofilm formation with all of the isolates in growth medium, supplementation with either synovial fluid or human serum inhibited bacterial surface attachment over a 24 h incubation. Surprisingly, there was no correlation between the degree of synovial fluid-induced aggregation and quantity of surface-associated biofilm as measured by a conventional biofilm assay without host fluid supplementation. Taken together, our findings suggest that synovial fluid-induced aggregation appears to be widespread among S. aureus strains and mechanistically independent of biofilm formation. IMPORTANCE Bacterial infections of hip and knee implants are rare but devastating complications of orthopedic surgery. Despite a widespread appreciation of the considerable financial, physical, and emotional burden associated with the development of a prosthetic joint infection, the establishment of bacteria in the synovial joint remains poorly understood. It has been shown that immediately upon exposure to synovial fluid, the viscous fluid in the joint, Staphylococcus aureus rapidly forms aggregates which are resistant to antibiotics and host immune cell clearance. The bacterial virulence associated with aggregate formation is likely a step in the establishment of prosthetic joint infection, and as such, it has the potential to be a potent target of prevention. We hope that this work contributes to the future development of therapeutics targeting synovial fluid-induced aggregation to better prevent and treat these infections.
Subject(s)
Bacterial Adhesion/physiology , Biofilms/growth & development , Prosthesis-Related Infections/microbiology , Staphylococcus aureus/growth & development , Synovial Fluid/microbiology , Animals , Cattle , Hip Prosthesis/microbiology , Humans , Knee Prosthesis/microbiology , Serum/microbiology , Staphylococcal Infections/drug therapy , Staphylococcus aureus/drug effects , Staphylococcus aureus/isolation & purification , Synovial Membrane/microbiologyABSTRACT
INTRODUCTION: Periprosthetic joint infection (PJI) represents a devastating complication of total joint arthroplasty associated with significant morbidity and mortality. Literature suggests a possible higher incidence of periprosthetic joint infection (PJI) in patients with rheumatoid arthritis (RA). There is, however, no consensus on this purported risk nor a well-defined mechanism. This study investigates how collagen-induced arthritis (CIA), a validated animal model of RA, impacts infectious burden in a well-established model of PJI. METHODS: Control mice were compared against CIA mice. Whole blood samples were collected to quantify systemic IgG levels via ELISA. Ex vivo respiratory burst function was measured via dihydrorhodamine assay. Ex vivo Staphylococcus aureus Xen36 burden was measured directly via colony forming unit (CFU) counts and crystal violet assay to assess biofilm formation. In vivo, surgical placement of a titanium implant through the knee joint and inoculation with S. aureus Xen36 was performed. Bacterial burden was then quantified by longitudinal bioluminescent imaging. RESULTS: Mice with CIA demonstrated significantly higher levels of systemic IgG compared with control mice (p = 0.003). Ex vivo, there was no significant difference in respiratory burst function (p = 0.89) or S. aureus bacterial burden as measured by CFU counts (p = 0.91) and crystal violet assay (p = 0.96). In vivo, no significant difference in bacterial bioluminescence between groups was found at all postoperative time points. CFU counts of both the implant and the peri-implant tissue were not significantly different between groups (p = 0.82 and 0.80, respectively). CONCLUSION: This study demonstrated no significant difference in S. aureus infectious burden between mice with CIA and control mice. These results suggest that untreated, active RA may not represent a significant intrinsic risk factor for PJI, however further mechanistic translational and clinical studies are warranted.
Subject(s)
Arthritis, Experimental , Arthroplasty, Replacement, Knee , Bone-Implant Interface , Knee Joint , Knee Prosthesis/microbiology , Staphylococcal Infections , Staphylococcus aureus/metabolism , Animals , Arthritis, Experimental/metabolism , Arthritis, Experimental/microbiology , Arthritis, Experimental/pathology , Bacterial Load , Bone-Implant Interface/microbiology , Bone-Implant Interface/pathology , Knee Joint/metabolism , Knee Joint/microbiology , Knee Joint/pathology , Knee Joint/surgery , Male , Mice , Risk Factors , Staphylococcal Infections/metabolism , Staphylococcal Infections/microbiology , Staphylococcal Infections/pathologyABSTRACT
Data demonstrating that antibiotics administered intraoperatively in patients with surgical revision for periprosthetic joint infection achieve concentrations exceeding minimal inhibitory concentrations of the identified bacteria at the surgical site when the new implant is inserted are lacking. We prospectively included patients with periprosthetic joint infection operated with one- or two-stage replacement during which cefepime (2g)-daptomycin (10mg/kg) combination was administered intravenously as intraoperative empirical antibiotic treatment. Three biopsies (two bones and one synovial membrane) were taken from each patient just before the insertion of the new implant. Eighteen adults of median age 68 years were included. Knee was involved in 10 patients (55.6%) and surgery consisted in one-/two-stage replacement in 11/7 patients. A tourniquet was used during the intervention in the 10 patients with knee prosthesis. Among 54 tissue samples, cefepime and daptomycin were detected respectively in 35 (64.8%) and 21 (38.9%) cases (P=0.01). A total of 17 bacteria dominated by staphylococci (n=14) were identified in 10 patients; tissue inhibitory quotient calculated in 51 samples was >1 in 22 cases (43.1%) for cefepime and in 16 cases (31.4%) for daptomycin. The proportion of tissue samples with detectable antibiotic was significantly higher in hip versus knee prosthesis (P=0.03). The present study suggests that intraoperative empirical administration of cefepime-daptomycin combination during septic prosthetic joint replacement results in a high proportion of tissue samples in which at least one of the two antibiotics was not detected or at a low concentration despite satisfactory concomitant blood serum concentrations.
Subject(s)
Anti-Bacterial Agents/administration & dosage , Cefepime/administration & dosage , Daptomycin/administration & dosage , Prosthesis-Related Infections/drug therapy , Aged , Drug Therapy, Combination , Female , Humans , Knee Prosthesis/microbiology , Male , Middle Aged , Prospective Studies , Prosthesis-Related Infections/microbiology , Staphylococcus/drug effects , Staphylococcus/genetics , Staphylococcus/isolation & purificationABSTRACT
There is increased awareness of the worldwide spread of specific epidemic multidrug-resistant (MDR) lineages of the human commensal Staphylococcus epidermidis. Here, using bioinformatic analyses accounting for population structure, we determined genomic traits (genes, SNPs and k-mers) that distinguish S. epidermidis causing prosthetic-joint infections (PJIs) from commensal isolates from nares, by analysing whole-genome sequencing data from S. epidermidis from PJIs prospectively collected over 10 years in Sweden, and contemporary S. epidermidis from the nares of patients scheduled for arthroplasty surgery. Previously suggested virulence determinants and the presence of genes and mutations linked to antimicrobial resistance (AMR) were also investigated. Publicly available S. epidermidis sequences were used for international extrapolation and validation of findings. Our data show that S. epidermidis causing PJIs differed from nasal isolates not by virulence but by traits associated with resistance to compounds used in prevention of PJIs: ß-lactams, aminoglycosides and chlorhexidine. Almost a quarter of the PJI isolates did not belong to any of the previously described major nosocomial lineages, but the AMR-related traits were also over-represented in these isolates, as well as in international S. epidermidis isolates originating from PJIs. Genes previously associated with virulence in S. epidermidis were over-represented in individual lineages, but failed to reach statistical significance when adjusted for population structure. Our findings suggest that the current strategies for prevention of PJIs select for nosocomial MDR S. epidermidis lineages that have arisen from horizontal gene transfer of AMR-related traits into multiple genetic backgrounds.
Subject(s)
Drug Resistance, Multiple, Bacterial , Hip Prosthesis/microbiology , Knee Prosthesis/microbiology , Staphylococcal Infections/microbiology , Staphylococcus epidermidis/classification , Whole Genome Sequencing/methods , Aged , Aged, 80 and over , Computational Biology , Female , Gene Transfer, Horizontal , Genomics , Humans , Male , Middle Aged , Phylogeny , Staphylococcus epidermidis/genetics , Staphylococcus epidermidis/isolation & purification , Staphylococcus epidermidis/pathogenicity , SwedenABSTRACT
Since the past decade, aspirin, a popular anti-inflammatory drug, has been increasingly studied for its potential antimicrobial and antibiofilm activity with promising results, but studies were limited to in vitro and in vivo investigations. Moreover, evidence concerning the beneficial effects of aspirin on the treatment of biofilm-related infections in real-world population is limited. Thus, this study aimed to investigate whether aspirin could promote infection control for patients with periprosthetic joint infections (PJIs). A single-center database was searched. Regular aspirin exposure was defined as a prescription of aspirin for > 6 months before diagnosis of PJIs and consecutive use during the PJI treatment course at a dose ⧠100 mg/day. General data, treatment modalities, and recurrence status were collected from medical records by an independent orthopedic surgeon. From January 01, 2010, to February 17, 2019, 88 patients who met the PJI criteria were identified and included in this study. Of these patients, 12 were taking aspirin regularly during the infectious events. In the Cox proportional hazards model, multivariate analysis revealed that the aspirin group demonstrated significant benefit via superior resolution of PJIs (HR 2.200; 95% CI 1.018-4.757; p = 0.045). In this study, aspirin is beneficial for infection resolution when combined with the current standard of PJI treatment and conventional antibiotics in the management of PJIs.
Subject(s)
Anti-Bacterial Agents/administration & dosage , Aspirin/administration & dosage , Hip Prosthesis/adverse effects , Knee Prosthesis/adverse effects , Prosthesis-Related Infections/drug therapy , Adult , Aged , Aged, 80 and over , Anti-Bacterial Agents/therapeutic use , Aspirin/therapeutic use , Case-Control Studies , Drug Therapy, Combination , Female , Hip Prosthesis/microbiology , Humans , Knee Prosthesis/microbiology , Male , Middle Aged , Multivariate Analysis , Treatment OutcomeABSTRACT
Knee joint infection following total knee arthroplasty (TKA) is a serious condition and the treatments are complicated. The intra-articular solvent exchange-induced in situ forming matrix is of interest for modulating the release of antibiotics with a high drug concentration and a long period of exposed time at the target site. Stearic acid (S) and lauric acid (L) at various ratios were used as matrix formers by dissolving them in biocompatible solvents such as N-methyl pyrrolidone (NMP) and dimethyl sulfoxide (DMSO). Their matrix formation behaviors in phosphate buffer (pH7.4) and hyaluronic acid (HA) solution were evaluated. Also, the density, viscosity, injectability, solvent diffusion, in vitro degradability and drug release using the dialysis tube method were investigated. The L:S ratio of 1:1 in DMSO exhibited rapid matrix formation and a remarkably low viscosity (7.67±0.03 cp) with acceptable injectability (0.608±0.027N and 0.867±0.010N through 18-G and 27-G, respectively). Vancomycin HCl (V)-loaded L/S in situ forming matrix still provided ease of injection (1.079±0.215N and 1.230±0.145N through 18-G and 27-G needle, respectively) with fatty acid matrix formation after solvent exchange within 1min, whilst V sustainably released over 6days. It also presented effective antimicrobial activities against standard Staphylococcus aureus and methicillin-resistant Staphylococcus aureus strains. Therefore, V-loaded solvent exchange-induced in situ forming matrix using L and S as the matrix formers may be a potential local delivery system for treating knee joint infections occurring after TKA in the future.
Subject(s)
Knee Prosthesis/microbiology , Lauric Acids/chemistry , Prosthesis-Related Infections/prevention & control , Staphylococcus aureus/drug effects , Stearic Acids/chemistry , Vancomycin/pharmacology , Arthroplasty, Replacement, Knee/adverse effects , Dimethyl Sulfoxide/chemistry , Drug Liberation , Humans , Methicillin-Resistant Staphylococcus aureus/drug effects , Methicillin-Resistant Staphylococcus aureus/growth & development , Microbial Sensitivity Tests , Pyrrolidinones/chemistry , Solvents/chemistry , Staphylococcus aureus/growth & development , Vancomycin/chemistry , ViscosityABSTRACT
AIMS: Biopsy of the periprosthetic tissue is an important diagnostic tool for prosthetic joint infection (PJI) as it enables the detection of the responsible microorganism with its sensitivity to antibiotics. We aimed to investigate how often the bacteria identified in the tissue analysis differed between samples obtained from preoperative biopsy and intraoperative revision surgery in cases of late PJI; and whether there was a therapeutic consequence. METHODS: A total of 508 patients who required revision surgery of total hip arthroplasty (THA) (n = 231) or total knee arthroplasty (TKA) (n = 277) because of component loosening underwent biopsy before revision surgery. The tissue samples collected at biopsy and during revision surgery were analyzed according to the criteria of the Musculoskeletal Infection Society (MSIS). RESULTS: In total, 178 (113 THA, 65 TKA) were classified as infected. The biopsy procedure had a sensitivity of 93.8%, a specificity of 97.3%, a positive predictive value (PPV) of 94.9%, a negative predictive value (NPV) of 96.7%, and an accuracy of 96.1%. Of the 178 infected patients, 26 showed a difference in the detected bacteria from the biopsy and the revision surgery (14.6%). This difference required a change to antibiotic therapy in only two cases (1.1%). CONCLUSION: Biopsy is a useful tool to diagnose PJI, but there may be a difference in the detected bacteria between the biopsy and revision surgery. However, this did not affect the choice of antibiotic therapy in most cases, rendering the clinical relevance of this phenomenon as low. Cite this article: Bone Joint J 2020;102-B(3):329-335.
Subject(s)
Arthroplasty, Replacement, Hip/adverse effects , Arthroplasty, Replacement, Knee/adverse effects , Biopsy/methods , Delayed Diagnosis , Prosthesis-Related Infections/diagnosis , Adult , Aged , Aged, 80 and over , Bacteria/isolation & purification , Female , Follow-Up Studies , Hip Joint/microbiology , Hip Joint/pathology , Hip Joint/surgery , Hip Prosthesis/adverse effects , Hip Prosthesis/microbiology , Humans , Knee Joint/microbiology , Knee Joint/pathology , Knee Joint/surgery , Knee Prosthesis/adverse effects , Knee Prosthesis/microbiology , Male , Middle Aged , Prospective Studies , Prosthesis-Related Infections/microbiology , Reproducibility of ResultsABSTRACT
BACKGROUND: To mitigate the possibility of infection after arthroplasty, intraoperative irrigation is essential to remove contaminating bacteria. Previous studies have demonstrated that irrigation with an EDTA solution before wound closure is superior to irrigation with normal saline in removing contaminating bacteria in a rat model of open fractures. However, the effectiveness of an EDTA solution in a model with a contaminated intra-articular implant remains unclear. QUESTIONS/PURPOSES: (1) Does irrigation with an EDTA solution decrease the proportion of culture-positive joints compared with normal saline, benzalkonium chloride, and povidone iodine? (2) Is an EDTA solution toxic to cells resident in joints including chondrocytes, osteoblasts, and synovial fibroblasts? (3) Does irrigation with an EDTA solution have adverse effects including arthrofibrosis and hypocalcemia? METHODS: We first established a model of contaminated intra-articular implants. Female Sprague-Dawley rats (n = 30 for each treatment group) underwent knee arthrotomy and implantation of a femoral intramedullary wire with 1 mm of intra-articular communication. To simulate bacterial contamination, the inserted wire was inoculated with either Staphylococcus aureus or Escherichia coli. After 1 hour, the wound and implant were irrigated with normal saline, benzalkonium chloride, povidone iodine, or an EDTA solution (1 mM). The animals were euthanized 1 week later, and the distal femur, knee capsule, and implanted wire were harvested for bacterial culture using standard techniques. In this study, we used a well-established animal model of an intra-articular implant and inoculated the implant to simulate the clinical setting of intraoperative contamination. The proportion of culture-positive joints in normal saline, benzalkonium chloride, povidone-iodine, and EDTA groups were compared. The viable cell numbers (chondrocytes, osteoblasts, and synovial fibroblasts) were counted and compared after treatment with either solution. Measurement of blood calcium level and histological examination of the joint were performed to rule out hypocalcemia and arthrofibrosis after EDTA irrigation. RESULTS: With S. aureus inoculation, EDTA irrigation resulted in fewer culture-positive joints than normal saline (37% [11 of 30] versus 70% [21 of 30]; p = 0.019), benzalkonium chloride (83% [25 of 30]; p < 0.001), and povidone iodine (83% [25 of 30]; p < 0.001) irrigation. Likewise, infection rates for implant inoculation with E. coli were also lower in the EDTA irrigation group (13% [four of 30]) than in the normal saline (60% [18 of 30]; p < 0.001), benzalkonium chloride (77% [23 of 30]; p < 0.001), and povidone iodine (80% [24 of 30]; p < 0.001) groups. Between normal saline control and EDTA, there were no differences in cell viability in chondrocytes (normal saline: 98% ± 18%; EDTA: 105% ± 18%; p = 0.127), osteoblasts (normal saline: 102 ± 19%, EDTA: 103 ± 14%; p = 0.835), and synovial fibroblasts (normal saline: 101% ± 21%, EDTA: 110% ± 13%; p = 0.073). EDTA irrigation did not result in hypocalcemia (before irrigation: 2.21 ± 0.32 mmol/L, after irrigation: 2.23 ± 0.34 mmol/L; p = 0.822); and we observed no arthrofibrosis in 30 histologic samples. CONCLUSIONS: In a rat model of a bacteria-contaminated intra-articular implants, intraoperative irrigation with 1 mmol/L of an EDTA solution was superior to normal saline, 0.03% benzalkonium chloride, and 0.3% povidone iodine in preventing surgical-site infection and caused no adverse effects including death of resident cells, arthrofibrosis, and hypocalcemia. Future studies should seek to replicate our findings in other animal models, perhaps such as dog and goat. CLINICAL RELEVANCE: If other animal models substantiate the efficacy and safety of the EDTA solution, clinical trials would be warranted to determine whether the use of an EDTA irrigation solution might reduce the risk of periprosthetic joint infections in patients compared with traditional irrigation solutions.
Subject(s)
Anti-Infective Agents, Local/therapeutic use , Edetic Acid/therapeutic use , Escherichia coli Infections/therapy , Knee Prosthesis/microbiology , Staphylococcal Infections/therapy , Surgical Wound Infection/therapy , Therapeutic Irrigation , Animals , Escherichia coli Infections/drug therapy , Escherichia coli Infections/microbiology , Female , Models, Animal , Rats , Rats, Sprague-Dawley , Staphylococcal Infections/drug therapy , Staphylococcal Infections/microbiology , Surgical Wound Infection/drug therapy , Surgical Wound Infection/microbiology , Treatment OutcomeABSTRACT
Biofilm-active antibiotics are suggested to improve the outcome in periprosthetic joint infection (PJI). However, the type, dose and duration of antibiotic treatment is rarely specified and their impact on outcomes is unknown. In this prospective cohort study, the infection and functional outcome were compared in 131 patients with knee PJI treated with or without biofilm-active antibiotics. The infection and functional outcome were evaluated by the Kaplan-Meier survival method to estimate the probability of infection-free survival; comparison between subgroups was performed by log-rank test. The influence of variables on the survival probability was analysed using univariate and multivariate Cox proportional-hazards regression models. Functional outcome was evaluated by pain intensity and the Knee injury and Osteoarthritis Outcome Score (KOOS). Among the 131 patients, 55 (42%) were treated with biofilm-active antibiotics and 76 (58%) were treated with non-biofilm-active antibiotics. The median follow-up period was 3.7 years (range, 2.0-7.6 years), and the infection-free survival probability was 74% (95% CI 61-85%) after 1 year and 56% (95% CI 47-66%) after 2 years. Infection-free survival after 1 year was better for patients who received biofilm-active antibiotics compared with those who did not (83% vs. 70%; P = 0.040) and remained superior after 2 years (67% vs. 48%; P = 0.038). In addition, biofilm-active antibiotic treatment was associated with lower pain intensity (P = 0.006) and higher KOOS on all five subscales. In patients with knee PJI, biofilm-active antibiotic therapy was associated with better infection outcome, lower pain intensity and better joint function.
Subject(s)
Anti-Bacterial Agents/therapeutic use , Arthroplasty, Replacement, Knee/adverse effects , Biofilms/drug effects , Knee Prosthesis/microbiology , Prosthesis-Related Infections/drug therapy , Adult , Aged , Aged, 80 and over , Debridement , Female , Humans , Male , Middle Aged , Pain/prevention & control , Prospective Studies , Prosthesis-Related Infections/microbiology , Treatment OutcomeABSTRACT
CASE: A patient who underwent first-stage revision procedure elsewhere for prosthetic joint infection (PJI) of the knee with Kocuria rosea presented to us 9 months after the index surgery, with persistent infection. First-stage revision surgery was repeated and Mycobacterium wolinskyi, a rare rapidly growing nontuberculous mycobacterium (RGM), was isolated from samples obtained by sonication of the cement spacer. After a prolonged antibiotic course, definitive implantation surgery was done. One-year postimplantation, patient remains infection free. CONCLUSIONS: This is only the second known case of knee PJI caused by M. wolinskyi. This case highlights the possibility of RGM getting masked by other organisms.
Subject(s)
Arthritis, Infectious/microbiology , Arthroplasty, Replacement, Knee/adverse effects , Knee Prosthesis/microbiology , Mycobacteriaceae/isolation & purification , Prosthesis-Related Infections/microbiology , Humans , Male , Middle AgedABSTRACT
Tuberculosis (TB) affecting a prosthetic knee is an unusual and diagnostically challenging presentation of this disease. This study reported a case of an 80-year-old man with a left total knee arthroplasty (TKA) performed eight years before his presentation. He presented with left knee swelling and pain for one month. Knee X-rays showed a normal joint space with no loosening of his prosthesis. His chest X-ray showed miliary disease, and microbiological studies of his sputum and synovial fluid aspirate grew Mycobacteria tuberculosis complex. He was successfully medically treated with anti-tuberculous therapy alone for one year. His knee hardware was retained, and he did not require debridement, resection, or revision. It is believed that this is the first reported case of miliary TB with delayed-onset TKA prosthetic joint infection (PJI) in which the prosthesis was successfully retained. Thirty-eight published TB TKA PJI cases in medical literature were also reviewed.
Subject(s)
Antitubercular Agents/therapeutic use , Arthritis, Infectious/transmission , Arthroplasty, Replacement, Knee/adverse effects , Knee Joint/diagnostic imaging , Knee Prosthesis/adverse effects , Prosthesis-Related Infections/therapy , Tuberculosis, Miliary/therapy , Aged, 80 and over , Arthritis, Infectious/diagnosis , Arthritis, Infectious/microbiology , Humans , Knee Joint/microbiology , Knee Joint/surgery , Knee Prosthesis/microbiology , Male , Mycobacterium tuberculosis/isolation & purification , Prosthesis-Related Infections/diagnosis , Prosthesis-Related Infections/microbiology , Radiography , Tuberculosis, Miliary/diagnosis , Tuberculosis, Miliary/microbiologyABSTRACT
BACKGROUND: Despite the availability of several biomarkers, the diagnosis of periprosthetic joint infection (PJI) continues to be challenging. Serum D-dimer assessment is a widely available test that detects fibrinolytic activities and has been reported as an inflammatory biomarker. However, quite a few articles have reported the diagnostic efficiency of D-dimer for PJI. METHODS: This prospective study enrolled patients who had undergone total joint arthroplasty, were suspected of PJI, and also prepared for revision arthroplasty. PJI was defined using the Musculoskeletal Infection Society criteria. In all patients, serum D-dimer level, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) level were measured preoperatively. We then compared the diagnostic efficiency of these three biomarkers. RESULTS: The median D-dimer level was significantly higher (p < 0.001) for the patients with PJI than for the patients with aseptic failure. With a sensitivity of 80.77% (95% CI, 65.62 to 95.92%) and a specificity of 79.63% (95% CI, 68.89 to 90.37%), the diagnostic efficiency of D-dimer did not outperform serum CRP (with a sensitivity of 84.61% and specificity of 64.81%) and ESR (with a sensitivity of 73.08% and specificity of 90.47%). CONCLUSIONS: Serum D-dimer as a marker for the diagnosis of PJI still requires more large-scale and detailed clinical trials.
Subject(s)
Blood Sedimentation , C-Reactive Protein/metabolism , Fibrin Fibrinogen Degradation Products/metabolism , Hip Prosthesis/adverse effects , Knee Prosthesis/adverse effects , Prosthesis-Related Infections/blood , Adult , Aged , Arthroplasty, Replacement, Hip/adverse effects , Arthroplasty, Replacement, Knee/adverse effects , Biomarkers/blood , Biomarkers/metabolism , Female , Hip Prosthesis/microbiology , Humans , Knee Prosthesis/microbiology , Male , Middle Aged , Prospective Studies , Prosthesis-Related Infections/diagnosisABSTRACT
Objective: To determine the prevalence and virulence factors of coagulase-negative Staphylococci (CNS) in prosthetic joint infections (PJI). Method: CNS were isolated of 66 hip and knee PJI from Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, México City. Antimicrobial susceptibility and biofilm formation in CNS were determined; icaADBC, aap, bap and embp genes were determined by PCR. Results: Staphylococcus and Staphylococcus hominis were the most prevalent with 82 y 80% respectively. Staphylococcus lugdunensis, Staphylococcus haemolyticus, Staphylococcus capitis, Staphylococcus caprae, Staphylococcus sciuri and Staphylococcus lentus were less frequent. The majority of isolates were resistant to ß-lactam antibiotics, fluoroquinolone, and erythromycin. 41% of CNS were biofilm former and 59% were non-biofilm former (p = 0.0551). Biofilm former Staphylococcus epidermidis showed a high presence of icaADBC, aap and embp operons compared to the non-biofilm former isolates (p < 0.05). In contrast, non-S. epidermidis CNS had only the aap gen. Conclusion: S. haemolyticus, S. sciuri and S. lentus are new isolates of PJI not previously reported with virulence factors similar to CNS isolates.
Objetivo: Estudiar la prevalencia y los factores de virulencia de Staphylococcus coagulasa negativos (SCN) de infecciones de prótesis articular (IPA). Método: Los SCN se aislaron de 66 pacientes con IPA de cadera y rodilla procedentes del Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, de Ciudad de México. Se determinaron la sensibilidad antimicrobiana y la producción de biopelículas de los SCN. Los genes icaADBC, aap, bap y embp fueron detectados por reacción en cadena de la polimerasa en SCN. Resultados: La IPA de cadera fue el 80%. Se aislaron en alta proporción S. epidermidis (82%) y S. hominis (80%), y en baja frecuencia S. lugdunensis, S. haemolyticus, S. capitis, S. caprae, S. sciuri y S. lentus. La mayoría de los aislamientos fueron resistentes a los betalactámicos, las fluoroquinolonas y la eritromicina. La producción de biopelículas se determinó en el 41% de los SCN y el 59% fueron no productores de biopelículas (p = 0.0551). S. epidermidis productores de biopelículas tuvieron mayor presencia del operón icaADBC, aap y embp que los aislamientos no productores de biopelícula (p < 0.05). Los SCN no S. epidermidis presentaron únicamente el gen aap. Conclusiones: S. haemolyticus, S. sciuri y S. lentus son aislamientos nuevos de IPA no reportados que poseen factores de virulencia, igual que las otras especies de SCN aisladas.