A mean 4-year evaluation of infection control rates of hip and knee prosthetic joint infection-related revision arthroplasty: an observational study.

BACKGROUND AND PURPOSE: The long-term results of the 1- or 2-stage revision procedure and infection-free prosthesis survival in a tertiary referral center are unknown. In this retrospective observational study, the long-term results of infection control and infection-free prosthesis survival of the periprosthetic joint infection-related 1- and 2-stage revision procedure are evaluated. Furthermore, the merits of performing an antibiotic-free window in the 2-stage revision is evaluated. PATIENTS AND METHODS: All patients who received a 1- or 2-stage revision procedure of the hip or knee between 2010 and 2017 were included. Data was collected on patient and infection characteristics. The primary treatment aim was successful infection control without the use of antibiotic therapy afterwards. Infection-free survival analysis was performed using the Kaplan-Meier method with type of periprosthetic joint infection-related revision as covariate. Within the group of 2-stage revisions, use of an antibioticfree window was selected as covariate. RESULTS: 128 patients were treated for a periprosthetic joint infection-related revision procedure (81 hips and 47 knees). Successful infection control was achieved in 18 of 21 cases for the 1-stage and 89 out of 107 cases for the 2-stage revision procedure (83%) respectively after follow-up of more than 4 years. In addition, 2-stage revision procedure infection control was achieved in 52 of 60 cases with an antibiotic-free interval and 37 of 45 cases without such interval (p = 0.6). The mean infection-free survival of the 1-stage revision was 90 months (95% CI 75-105) and 98 months (CI 90-106) for the 2-stage revision procedure. INTERPRETATION: There seems to be no difference in infection control and infection-free survival between the 1- and 2-stage revision procedure. Second, an antibiotic-free window in the case of a 2-stage revision did not seem to influence treatment outcome. However, one must be cautious when interpreting these results due to confounding by indication and the small study population. Therefore, no definite conclusion can be drawn.

False amoxicillin/clavulanic acid susceptibility in Bacteroides fragilis using gradient strip tests.

BACKGROUND: Repeatedly, too low MIC results were obtained in Bacteroides fragilis quality assessment strains, using gradient strip tests with a ratio of amoxicillin:clavulanic acid of 2:1. We aimed to find the most accurate available gradient strip tests for susceptibility testing of amoxicillin/clavulanic acid in B. fragilis in comparison with agar dilution with EUCAST methodology and breakpoints. METHODS: Twenty-seven clinical B. fragilis isolates were investigated using gold standard EUCAST amoxicillin/clavulanic acid agar dilution (fixed clavulanic acid concentration at 2 mg/L, with increasing amoxicillin concentrations) as well as three commercial gradient strip tests: XL (ratio), AUG (ratio) or AMC (fixed concentration). RESULTS: Using agar dilution (fixed concentration), 19 isolates were susceptible, 1 isolate was susceptible increased exposure (I) and 7 isolates were resistant. Categorical agreement of the gradient strip tests with agar dilution (fixed concentration) was 70% for XL (ratio), 71% for AUG (ratio) and 89% for AMC (fixed concentration). Very major error rates in comparison with agar dilution (fixed concentration) were 100%, 0%, and 0%, respectively. CONCLUSIONS: EUCAST breakpoint usage in amoxicillin/clavulanic acid susceptibility tests for B. fragilis should be accompanied by EUCAST methodology. When using alternative methods such as gradient strip tests, a higher degree of alignment with EUCAST methodology, such as using fixed clavulanic acid concentrations, improves precision.

The added value of the selective SuperPolymyxin™ medium in detecting rectal carriage of Gram-negative bacteria with acquired colistin resistance in intensive care unit patients receiving selective digestive decontamination.

The objective of this study was to determine the value of using SuperPolymyxin™ selective medium (ELITech Group, Puteaux, France) in addition to conventional non-selective inoculation methods in the detection of acquired colistin resistance in a Dutch intensive care unit (ICU) that routinely uses selective decontamination of the digestive tract (SDD). We performed a cross-sectional study with prospective data collection in a tertiary-care ICU. All consecutive surveillance rectal swabs of ICU-patients receiving SDD were included and cultured in an observer-blinded approach using (1) a conventional culture method using non-selective media and (2) SuperPolymyxin™ selective medium. MIC values for colistin of non-intrinsically colistin-resistant Gram-negative isolates were determined with broth microdilution (BMD) using Sensititre™ and colistin resistance was confirmed using BMD according to EUCAST guidelines. One thousand one hundred five rectal swabs of 428 unique ICU-patients were inoculated using both culture methods, yielding 346 and 84 Gram-negative isolates for BMD testing with the conventional method and SuperPolymyxin™ medium, of which 308 and 80 underwent BMD, respectively. The number of identified rectal carriers of isolates with acquired colistin resistance was 3 (0.7%) for the conventional method, 4 (0.9%) for SuperPolymyxin™, and 5 (1.2%) for both methods combined. The number of isolates with acquired colistin resistance was 4 (1.0%) for the conventional method, 8 (2.1%) for SuperPolymyxin™ and 9 (2.3%) for both methods combined. In a surveillance setting of low prevalence of acquired colistin resistance in patients that receive SDD in a Dutch tertiary-care ICU, SuperPolymyxin™ had a higher diagnostic yield than conventional inoculation methods, but the combination of both had the highest diagnostic yield.

Identification of Neisseria gonorrhoeae by the Bruker Biotyper Matrix-Assisted Laser Desorption Ionization-Time of Flight Mass Spectrometry System Is Improved by a Database Extension.

Identification ofNeisseria gonorrhoeaeby the Bruker matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) system may be affected by "B consistency categorization." A supplementary database of 17N. gonorrhoeaemain spectra was constructed. Twelve of 64N. gonorrhoeaeidentifications were categorized with B consistency, which disappeared using the supplementary database. Database extension did not result in misidentification ofNeisseria meningitidis.

Predominant association of Raoultella bacteremia with diseases of the biliary tract.

A case series of 14 patients with Raoultella bacteremia was compared with 28 Klebsiella oxytoca and 28 Klebsiella pneumoniae bacteremia cases. Forty-three percent of Raoultella bacteremia cases were associated with biliary tract disease, compared to 32% and 22% of patients with K. oxytoca and K. pneumoniae bacteremia, respectively.

Comparison of MBT biotargets with MBT steel targets for matrix-assisted laser desorption/ionization time of flight mass spectrometry identifications of microorganisms in a clinical microbiology laboratory.

MALDI-TOF MS identifications of microorganisms in a clinical laboratory were investigated, comparing steel targets with MBT Biotargets. By using MBT Biotargets, the score values of yeast identifications increased, whereas the score values of Gram-negative bacteria decreased. Switching to MBT Biotargets did not negatively impact overall frequencies of high confidence identifications.

The effect of guideline-based antimicrobial therapy on the outcome of fracture-related infections (EAT FRI Study).

AIM: This study investigated the compliance with a guideline-based antibiotic regimen on the outcome of patients surgically treated for a fracture-related infection (FRI). METHOD: In this international multicenter observational study, patients were included when diagnosed with an FRI between 2015 and 2019. FRI was defined according to the FRI consensus definition. All patients were followed for at least one year. The chosen antibiotic regimens were compared to the published guidelines from the FRI Consensus Group and correlated to outcome. Treatment success was defined as the eradication of infection with limb preservation. RESULTS: A total of 433 patients (mean age 49.7 ± 16.1 years) with FRIs of mostly the tibia (50.6%) and femur (21.7%) were included. Full compliance of the antibiotic regime to the published guidelines was observed in 107 (24.7%) cases. Non-compliance was mostly due to deviations from the recommended dosing, followed by the administration of an alternative antibiotic than the one recommended or an incorrect use or non-use of rifampin. Non-compliance was not associated with a worse outcome: treatment failure was 12.1% in compliant versus 13.2% in non-compliant cases (p = 0.87). CONCLUSIONS: We report good outcomes in the treatment of FRI and demonstrated that minor deviations from the FRI guideline are not associated with poorer outcomes.

Quality of MALDI-TOF mass spectra in routine diagnostics: results from an international external quality assessment including 36 laboratories from 12 countries using 47 challenging bacterial strains.

OBJECTIVES: Matrix assisted laser desorption ionization-time of flight (MALDI-TOF) mass spectrometry (MS) is a widely used method for bacterial species identification. Incomplete databases and mass spectral quality (MSQ) still represent major challenges. Important proxies for MSQ are the number of detected marker masses, reproducibility, and measurement precision. We aimed to assess MSQs across diagnostic laboratories and the potential of simple workflow adaptations to improve it. METHODS: For baseline MSQ assessment, 47 diverse bacterial strains, which are challenging to identify by MALDI-TOF MS, were routinely measured in 36 laboratories from 12 countries, and well-defined MSQ features were used. After an intervention consisting of detailed reported feedback and instructions on how to acquire MALDI-TOF mass spectra, measurements were repeated and MSQs were compared. RESULTS: At baseline, we observed heterogeneous MSQ between the devices, considering the median number of marker masses detected (range = [2-25]), reproducibility between technical replicates (range = [55%-86%]), and measurement error (range = [147 parts per million (ppm)-588 ppm]). As a general trend, the spectral quality was improved after the intervention for devices, which yielded low MSQs in the baseline assessment as follows: for four out of five devices with a high measurement error, the measurement precision was improved (p-values <0.001, paired Wilcoxon test); for six out of ten devices, which detected a low number of marker masses, the number of detected marker masses increased (p-values <0.001, paired Wilcoxon test). DISCUSSION: We have identified simple workflow adaptations, which, to some extent, improve MSQ of poorly performing devices and should be considered by laboratories yielding a low MSQ. Improving MALDI-TOF MSQ in routine diagnostics is essential for increasing the resolution of bacterial identification by MALDI-TOF MS, which is dependent on the reproducible detection of marker masses. The heterogeneity identified in this external quality assessment (EQA) requires further study.

Does the Use of Local Antibiotics Affect Clinical Outcome of Patients with Fracture-Related Infection?

This international, multi-center study evaluated the effect of antibiotic-loaded carriers (ALCs) on outcome in patients with a fracture-related infection (FRI) and evaluated whether bacterial resistance to the implanted antibiotics influences their efficacy. All patients who were retrospectively diagnosed with FRI according to the FRI consensus definition, between January 2015 and December 2019, and who underwent surgical treatment for FRI at any time point after injury, were considered for inclusion. Patients were followed-up for at least 12 months. The primary outcome was the recurrence rate of FRI at follow-up. Inverse probability for treatment weighting (IPTW) modeling and multivariable regression analyses were used to assess the relationship between the application of ALCs and recurrence rate of FRI at 12 months and 24 months. Overall, 429 patients with 433 FRIs were included. A total of 251 (58.0%) cases were treated with ALCs. Gentamicin was the most frequently used antibiotic (247/251). Recurrence of infection after surgery occurred in 25/251 (10%) patients who received ALCs and in 34/182 (18.7%) patients who did not (unadjusted hazard ratio (uHR): 0.48, 95% CI: [0.29-0.81]). Resistance of cultured microorganisms to the implanted antibiotic was not associated with a higher risk of recurrence of FRI (uHR: 0.75, 95% CI: [0.32-1.74]). The application of ALCs in treatment of FRI is likely to reduce the risk of recurrence of infection. The high antibiotic concentrations of ALCs eradicate most pathogens regardless of susceptibility test results.

Performance and clinical significance of direct antimicrobial susceptibility testing on urine from hospitalized patients.

BACKGROUND: Urinary tract infections (UTIs) are common infections in the community and the hospital. With increasing antimicrobial resistance, specifically in the Gram-negative uropathogens, reliable, rapid antimicrobial susceptibility data would be useful to guide antimicrobial treatment. Direct antimicrobial susceptibility testing (DST) of urine with microscopic evidence of Gram-negative bacterial infection and its clinical significance was investigated in this study. METHODS: DST was performed by Kirby-Bauer disk diffusion method using undiluted urine as a non-standardized inoculum. Urine specimens with Gram-negative bacteria on microscopy were included. DST results from growth of Gram-negative bacteria were compared to routine antimicrobial susceptibility testing by Phoenix automated system (AST). Errors were scored as 'very major error' if susceptible by DST but resistant by AST and as 'major error' if resistant by DST but susceptible by AST. All other discrepancies were defined as 'minor error'. Discrepancies were resolved by determination of minimum inhibitory concentrations (MICs) using Etests. After discrepancy analysis, errors were scored as above using the Etest as the reference method. For analysis, specimens were divided into 3 categories: category A: 1 isolate found by DST as well as by routine culture; category B: 1 isolate detected by DST, but more than 1 isolate found on routine culture; category C: more than 1 isolate found by both DST and routine culture. The clinical significance of DST was determined prospectively by investigating the potential impact of DST on antimicrobial therapy. RESULTS: One hundred and sixteen urine specimens were included. For DST and AST there was agreement in 96% of 1152 comparisons in category A (n = 100), 88% of 41 comparisons in category B (n = 4), and 88% of 110 comparisons in category C (n = 12). The 64 discrepancies included 18 very major errors, 7 major errors, and 39 minor errors. Eight very major errors and 11 minor errors were not investigated because the isolates were not available. After Etest MIC determination for the 45 remaining discrepancies, DST showed 1 very major error, 1 major error, and 8 minor errors in category A, none in category B, and 5 major errors and 4 minor errors in category C. Antimicrobial therapy for UTI was prescribed for 53 patients. For 4 patients (8%) therapy was adjusted based on DST because of antimicrobial resistance and for 12 patients (23%) antimicrobial treatment could have been streamlined. CONCLUSIONS: DST on urine is reliable in monobacterial Gram-negative infections. With increasing antimicrobial resistance, DST can make an important contribution to patient management and reduce the use of broad-spectrum antimicrobials.

Diagnostic value of routine chest tube tip culture in surgery for noninfectious lung disease.

BACKGROUND: Evaluation of the diagnostic value of routine chest tube tip culture for detection of postoperative infection after surgery for noninfectious lung disease. METHODS: Included subjects were patients who underwent lung surgery between January 1st 2013 and January 1st 2018 in University Medical Centre Utrecht and of whom a chest tube tip was cultured. Postoperative outcomes included pneumonia, surgical site infection, and empyema within 30 days after surgery. Univariable analysis for diagnostic accuracy of chest tube tip culture results predicting these postoperative outcomes was performed, as well as multivariable analysis using penalized firth logistic regression. RESULTS: Patients developed one or more postoperative infections in 42 out of 210 (20%) lung surgeries. Pneumonia, surgical site infection, and empyema were found in 36 (17%), 8 (4%), and 2 (1%) cases respectively. Chest tube tip culture had a sensitivity of 31%, a specificity of 83%, a positive predictive value of 32%, and a negative predictive value of 83% for postoperative infections. In the subgroup of patients who did not have evidence of postoperative infection at the time of chest tube removal, the drain tip culture's positive and negative predictive value changed to 18% and 92% respectively. Adding additional variables to chest tube tip culture in a prediction model resulting in only limited improvement in diagnostic performance. CONCLUSIONS: We found insufficient diagnostic performance to support the practice of routine chest tube tip culture after surgery for noninfectious lung disease. Therefore, routine chest tube tip culture is not advisable and should be omitted to unburden the healthcare process and prevent low value care together with extra costs.

One-year infection control rates of a DAIR (debridement, antibiotics and implant retention) procedure after primary and prosthetic-joint-infection-related revision arthroplasty - a retrospective cohort study.

Introduction: Debridement, antibiotics and implant retention (DAIR) procedures are effective treatments for acute postoperative or acute hematogenous periprosthetic joint infections. However, literature reporting on the effectiveness of DAIR procedures performed after a one- or two-stage revision because of a prosthetic joint infection (PJI) (PJI-related revision arthroplasty) is scarce. The aim of this study is to retrospectively evaluate the infection control after 1 year of a DAIR procedure in the case of an early postoperative infection either after primary arthroplasty or after PJI-related revision arthroplasty. Materials and methods: All patients treated with a DAIR procedure within 3 months after onset of PJI between 2009 and 2017 were retrospectively included. Data were collected on patient and infection characteristics. All infections were confirmed by applying the Musculoskeletal Infection Society (MSIS) 2014 criteria. The primary outcome was successful control of infection at 1 year after a DAIR procedure, which was defined as the absence of clinical signs, such as pain, swelling, and erythema; radiological signs, such as protheses loosening; or laboratory signs, such as C-reactive protein (CRP) ( < 10 ) with no use of antibiotic therapy. Results: Sixty-seven patients were treated with a DAIR procedure (41 hips and 26 knees). Successful infection control rates of a DAIR procedure after primary arthroplasty ( n = 51 ) and after prior PJI-related revision arthroplasty ( n = 16 ) were 69 % and 56 %, respectively ( p = 0.38 ). The successful infection control rates of a DAIR procedure after an early acute infection ( n = 35 ) and after a hematogenous infection ( n = 16 ) following primary arthroplasty were both 69 % ( p = 1.00 ). Conclusion: In this limited study population, no statistically significant difference is found in infection control after 1 year between DAIR procedures after primary arthroplasty and PJI-related revision arthroplasty.

Sonication Leads to Clinically Relevant Changes in Treatment of Periprosthetic Hip or Knee Joint Infection.

Background: Diagnosis of periprosthetic joint infection (PJI) can be troublesome. Sonication can be a helpful tool in culturing bacteria that are difficult to detect with standard tissue cultures. Aim of this study is to evaluate the clinical importance of our standardized sonication protocol in detecting periprosthetic joint infection. Materials and methods: All patients with revision surgery of a hip or knee prosthesis between 2011 and 2016 were retrospectively reviewed and divided in two groups: clinically suspected of infection or not suspected of infection. For both tissue culture and implant sonication, calculations of sensitivity and specificity were performed. Clinical relevance of sonication was evaluated by calculating in which percentage of patients' sonication influenced clinical treatment. Results: 226 patients with revision of a total hip prosthesis (122 patients) or a total knee prosthesis (104 patients) were included. Sensitivity of perioperatively taken tissue cultures was 94.3% and specificity was 99.3%. For sonication sensitivity was 80.5% and specificity was 97.8%. In the infection group eight patients (9%) with only one positive tissue culture and a positive sonication fluid culture with the same pathogen were found. Interpretation: Although sensitivity and specificity of sonication was lower compared to tissue cultures, periprosthetic joint infection could only be established in 8 patients (9%) suspected of infection because of a positive result of the sonication fluid culture. Sonication leads to clinically relevant changes in treatment and seems therefore to be a helpful diagnostic tool in clinical practice.

Two cases of Mycobacterium microti-induced culture-negative tuberculosis.

We present descriptions of two human Mycobacterium microti infections: one of a patient with pulmonary disease and one of a patient with osteomyelitis of the hip. Both patients had acid-fast bacilli and a positive Mycobacterium tuberculosis complex PCR from clinical specimens, but mycobacterial cultures remained negative. The microbiological diagnosis was established by molecular methods.

Reproducibility between two readout methods of a commercial broth microdilution assay for Pseudomonas aeruginosa isolates from patients with Cystic Fibrosis.

BACKGROUND: Pseudomonas aeruginosa isolates from Cystic fibrosis (CF) patients are growing slowly, and frequently rendering automated susceptibility testing unsuitable. Colistin is an important antibiotic for treatment of P. aeruginosa infections. Broth microdilution is the only EUCAST endorsed antimicrobial susceptibility test for colistin. The VIZION™ device aids in reading broth microdilution plates and allows safe data transfer to laboratory information systems. In this study, reproducibility between visual MIC readout and readout, employing the VIZION™ device was assessed in susceptibility testing of colistin and beta-lactam antibiotics in P. aeruginosa isolates from CF patients. METHODS: Fifty-six unique P. aeruginosa isolates were derived from respiratory secretions of CF patients. Susceptibility testing was performed using commercially available microdilution plates. MIC readout by VIZION™ was compared to visual readout aided by a mirror (reference test). RESULTS: Pseudomonas aeruginosa isolates displayed significantly slower growth rates compared to quality control isolates. Colistin exact MIC agreement between VIZION™ and visual readout after 24 and 48 h incubation, respectively, was 82% and 95%, essential MIC agreement was 98% and 100%, categorical agreement was 98% and 98% and reliability (weighted kappa) was 0.95 (95% CI = 0.91-0.99) and 0.99 (95% CI = 0.97-1.00). For all five antibiotics, the total number of errors (using VIZION™, in comparison with visual readout) decreased from 15 (5%) to 10 (4%) after 24 and 48 h incubation, respectively. CONCLUSIONS: VIZION™ readout reproducibly determines MIC values in comparison with visual readout after 24 h of incubation. Reproducibility between the VIZION™ and visual readout increases after prolonged incubation of 48 h.

INNO-LiPA DNA line probe assay misidentification of M. smegmatis as Mycobacterium fortuitum complex.

Seven weeks after being kicked in the face by a cow, a 34-year-old male patient developed a posttraumatic mycobacterial lymphadenitis. A rapidly growing mycobacterial isolate cultured from a surgically drained lymphadenitis pus specimen was identified as Mycobacterium smegmatis by matrix-assisted laser desorption/ionization mass spectrometry and a combination of ITS-, hsp65-, and 16S rRNA-DNA sequence analysis, but as Mycobacterium fortuitum complex using the commercial INNO-LiPA Mycobacteria v2 line probe assay. As it is unclear if the misidentification of this strain is an exception, more research is required.

Fatal Carbapenem Resistance Development in Pseudomonas Aeruginosa Under Meropenem Monotherapy, Caused by Mutations in the OprD Outer Membrane Porin.

A 13-year old neutropenic boy succumbed to bacteremia and sepsis with a Pseudomonas aeruginosa strain that rapidly developed resistance to carbapenems during meropenem monotherapy. Whole genome sequencing of the susceptible and resistant blood culture isolates revealed the meropenem-resistant phenotype to be caused by truncation of the OprD gene, which added to a preexisting inactivated mexR gene.

Specific cross-reactivity in sera from cystic echinococcosis patients in an enzyme-linked immunoelectrotransfer blot for cysticercosis diagnostics.

A commercially available enzyme-linked immunoelectrotransfer blot originally intended for diagnosis of cysticercosis was evaluated for echinococcosis diagnosis, because a characteristic band pattern--different from the specific cysticercosis pattern--was observed in sera from patients with echinococcosis. This band pattern was observed in 29 (78%) of 37 parasitologically proven cystic echinococcosis patients. Specificity of these bands was 100% for echinococcosis, when tested with 75 control sera.