Prevalence and prognostic relevance of invasive fungal disease during veno-arterial ECMO: A retrospective single-center study.

PURPOSE: To assess the prevalence and relevance of invasive fungal disease (IFD) during veno-arterial (V-A) extracorporeal membrane oxygenation (ECMO). METHODS: Retrospective analysis from January 2013 to November 2023 of adult V-A ECMO cases at a German University Hospital. Parameters relating to IFD, demographics, length of stay (LoS), days on ECMO and mechanical ventilation, prognostic scores and survival were assessed. Multivariable logistic regression analyses with IFD and death as dependent variables were performed. Outcome was assessed after propensity score matching IFD-patients to non-IFD-controls. RESULTS: 421 patients received V-A ECMO. 392 patients with full electronic datasets were included. The prevalence of IFD, invasive candidiasis and probable invasive pulmonary aspergillosis was 4.6%, 3.8% and 1.0%. Severity of acute disease, pre-existing moderate-to-severe renal disease and continuous kidney replacement therapy were predictive of IFD. In-hospital mortality (94% (17/18) compared to 67% (252/374) in non-IFD patients (p = 0.0156)) was predicted by female sex, SOFA score at admission, SAVE score and IFD (for IFD: OR: 8.31; CI: 1.60-153.18; p: 0.044). There was no difference in outcome after matching IFD-cases to non-IFD-controls. CONCLUSIONS: IFD are detected in about one in 20 patients on V-A ECMO, indicating mortality >90%. However, IFD do not contribute to prognosis in this population.

Description of Standardized Planes and Angles for Percutaneous Supra-acetabular Screw Placement.

BACKGROUND: Percutaneous screw fixation for pelvic fractures has become a minimally invasive alternative to an open operation. The complex anatomy of the pelvis renders this procedure challenging. The objective of this study was to assess standardized angles and dimensions of safety zones within a 3 D computed tomography model for optimal supra-acetabular screw placement. METHODS: Computed tomography scans of 107 patients that suffered major trauma without showing any bone injury of the pelvis were collected. Using a software-based analysis, raw computed tomography data were transformed into 3 D models to set standardized landmarks and determine the possible insertion corridor. RESULTS: Screws not exceeding a length of 97 mm in females and 106.4 mm in males were, in 95% of the evaluated cases, insertable without cortical bone penetration. The safety zone was 6.6 mm for females and 7.9 mm for males. Screws not exceeding these diameters were safely insertable in 95% of the cases. For the midsagittal plane, the angle was 36.4 ± 5.1 on the left and 34.7 ± 2.9 on the right (p = 0.008). For the anterior pelvic plane, the angle was 31.3 ± 4.5° on the left and 34.0 ± 4.8° on the right (p = 0.008). CONCLUSIONS: Percutaneous fixation using supra-acetabular screws is a promising method to treat simple supra-acetabular fractures. These results may improve its safe utilization and could facilitate its broader clinical application.

Sonication in Patients With Spinal Cord Stimulation: A New Approach for Infection Diagnostics.

INTRODUCTION: Spinal cord stimulation (SCS) offers improvement in pain and function for several chronic pain conditions. There are concerns regarding bacterial colonization of the temporary lead extensions and subsequent infection risk in a two-session implantation procedure. Although there is no standardized evaluation of SCS lead contamination, this study evaluates the infection rate and microbial colonization of SCS lead extensions with sonication, a method that is established in implant-related infection diagnostics. MATERIALS AND METHODS: This prospective observational study comprised 32 patients with a two-stage SCS implantation procedure. Microbial colonization of the lead extensions was assessed with sonication. The presence of organisms in the subcutaneous tissue was evaluated separately. Surgical-site infections were recorded. Patient demographics and risk factors including diabetes, tobacco use, obesity, trial length, and infection parameters in serum were recorded and analyzed. RESULTS: The mean age of the patients was 55 years. On average, the trial length was 13 days. In seven cases (21.9%), a microbial lead colonization was found with sonication. In contrast, there was one positive culture (3.1%) from the subcutaneous tissue samples. The C-reactive protein and leukocyte count remained at the preoperative level. One early surgical-site infection (3.1%) occurred. No other late infections occurred six months after surgery. CONCLUSIONS: There is a discrepancy between the presence of microbial colonization and the occurrence of clinically relevant infections. Although the rate of microbial colonization of the lead extensions is high (21.9%), the surgical-site infection rate remained low (3.1%). Therefore, we can conclude that the two-session procedure is a safe approach that is not associated with a higher incidence of infection. Although the sonication method cannot be used as the sole tool for detecting infections in patients with SCS, it can provide additional value in microbial diagnostics in combination with clinical and laboratory parameters and conventional microbiological methods.

Periprosthetic joint infection caused by kytococcus schroeteri: The first reported case and a review of the literature.

Oftentimes, Gram-positive cocci are the cause for periprosthetic joint infections (PJI). Most of these infections include bacteria such as Staphylococcus aureus, Staphylococcus epidermidis or other coagulase-negative staphylococci. We here present the first case of a PJI caused by Kytococcus schroeteri. While being a Gram-positive coccus, it is very rarely the cause for infections in the human body. K. schroeteri is part of the micrococcus branch and often encountered as a symbiotic bacterium living on the skin. Regarding its pathogenic potential, not a lot is known since less than a few dozen human infections have been reported worldwide. Furthermore, many of the cases reported are either associated with implanted material, especially heart valves, or associated with patients whose immune response is deficient. Only 3 reports of osteoarticular infections are described so far.

Microbiological Trends and Antibiotic Susceptibility Patterns in Patients with Periprosthetic Joint Infection of the Hip or Knee over 6 Years.

We sought to analyze trends of the causative pathogens and their antibiotic susceptibility patterns in patients with periprosthetic joint infections (PJI) of the hip and knee to get better insights and improve treatment. Retrospective evaluation of all consecutive patients with microbiological detection of a causative pathogen at a tertiary endoprothetic referral center between January 2016 and December 2021 in Germany was performed. Overall, 612 different microorganisms could be detected in 493 patients (hip: n = 293; knee: n = 200). Evaluation did not show a change in the relative abundance of pathogens detected, with coagulase-negative staphylococci (n = 275; 44.9%) found frequently, followed by S. aureus (n = 86; 14.1%), Enterococcus species (n = 57; 9.3%), Streptococcus species (n = 48; 7.8%), and Gram-negative bacteria (n = 80; 13.1%). Evaluation of the antibiotic susceptibilities showed increasing rates of oxacillin-resistant coagulase-negative staphylococci (60.4%; 46.8−76.7%) and piperacillin-tazobactam-resistant Gram-negative bacteria (26.5%; 0−57.1%), although statistically not significant. Resistance of Gram-positive bacteria to vancomycin (<1%) and Gram-negative microorganisms to meropenem (1.25%) remained an exception. In summary, coagulase-negative staphylococci, as the most frequent pathogen, displayed a continuously high rate of oxacillin resistance. For the highest antimicrobial coverage in the case of an empiric therapy/unknown pathogen, vancomycin might be chosen. Level of evidence: IV.

Microbiological Profiles of Patients with Periprosthetic Joint Infection of the Hip or Knee.

Periprosthetic joint infections (PJI) are one of the most devastating consequences after total joint arthroplasty. We sought to analyze the causative pathogens of patients with PJI to get better insights and improve treatment. We performed a retrospective study of all patients with PJI of the hip and knee with microbiological detection of a causative pathogen at a tertiary endoprothetic referral center between January 2016 and March 2021. A total of 432 cases with PJI (hip: n = 250; knee: n = 182) were included. The most common causative pathogen were coagulase-negative staphylococci (n = 240; 44.2%), of which Staphylococcus epidermidis (n = 144; 26.7%) was the most frequently detected, followed by S. aureus (n = 77; 14.3%) and enterococci (n = 49; 9%). Gram-negative pathogens and fungi could be detected in 21% (n = 136) and 2.4% (n = 13) of all cases. Overall, 60% of all coagulase-negative staphylococci were oxacillin-resistant, while none of these displayed to be vancomycin-resistant. In summary, the majority of pathogens in cases of PJI could be identified as coagulase-negative staphylococci. For empirical therapy vancomycin might provide the highest antimicrobial coverage in case of an unknown pathogen.

German Multicenter Study Analyzing Antimicrobial Activity of Ceftazidime-Avibactam of Clinical Meropenem-Resistant Pseudomonas aeruginosa Isolates Using a Commercially Available Broth Microdilution Assay.

Multidrug resistance is an emerging healthcare issue, especially concerning Pseudomonas aeruginosa. In this multicenter study, P. aeruginosa isolates with resistance against meropenem detected by routine methods were collected and tested for carbapenemase production and susceptibility against ceftazidime-avibactam. Meropenem-resistant isolates of P. aeruginosa from various clinical materials were collected at 11 tertiary care hospitals in Germany from 2017−2019. Minimum inhibitory concentrations (MICs) were determined via microdilution plates (MICRONAUT-S) of ceftazidime-avibactam and meropenem at each center. Detection of the presence of carbapenemases was performed by PCR or immunochromatography. For meropenem-resistant isolates (n = 448), the MIC range of ceftazidime-avibactam was 0.25−128 mg/L, MIC90 was 128 mg/L and MIC50 was 16 mg/L. According to EUCAST clinical breakpoints, 213 of all meropenem-resistant P. aeruginosa isolates were categorized as susceptible (47.5%) to ceftazidime-avibactam. Metallo-ß-lactamases (MBL) could be detected in 122 isolates (27.3%). The MIC range of ceftazidime-avibactam in MBL-positive isolates was 4−128 mg/L, MIC90 was >128 mg/L and MIC50 was 32 mg/L. There was strong variation in the prevalence of MBL-positive isolates among centers. Our in vitro results support ceftazidime-avibactam as a treatment option against infections caused by meropenem-resistant, MBL-negative P. aeruginosa.

Increased rate of enteric bacteria as cause of periprosthetic joint infections in patients with liver cirrhosis.

INTRODUCTION: Periprosthetic joint infections (PJI) are a major complication in joint-arthroplasty. Rifampicin is often used as an additional agent to treat PJI, because it penetrates bacterial biofilms. However, rifaximin, belonging to the same antibiotic class as rifampicin, is frequently used to prevent episodes of hepatic encephalopathy in patients with cirrhosis and may induce resistance to rifampicin. The aim of this study was to examine the microbial pattern of periprosthetic joint infections in cirrhotic patients and to test the hypothesis that intake of rifaximin increases the rate of resistance to rifampicin in periprosthetic joint infections. METHODS: A cohort of cirrhotic patients and PJI (n = 25) was analysed on the characteristics of bacterial isolates from sonication and tissue analysis. In a second step a subgroup analysis on the development of rifampicin resistant bacterial specimens, depending on the intake of rifaximin (8 rifaximin intake patients vs. 13 non rifaximin intake patients) was performed. RESULTS: Intestinal bacteria were found in 50% of the specimens, which was significantly more frequent than in a control cohort. By comparison of the single bacterial isolates, rifampicin resistance was detected in 69.2% (9/13) of the rifaximin-intake samples. In contrast, the non-rifaximin-intake isolates only were resistant to rifampicin in 22.2% (4/18) of the cases (p = 0.01). The odds ratio for developing a rifampicin-resistance through rifaximin intake was calculated as OR = 13.5. CONCLUSION: Periprosthetic joint infections have a high incidence of being caused by enteric bacteria in cirrhotic patients. Due to this change in microbial pattern and the innate resistance to rifampicin of most of gram-negative bacteria, the therapy with rifampicin should be carefully considered. The association between the use of rifaximin and developed resistance to rifampicin has a major impact on the treatment of PJI.

The psychological burden of a two-stage exchange of infected total hip and knee arthroplasties.

Infection is one of the most challenging complications after total joint arthroplasties affecting up to 30,000 patients in the US per year. This study investigates the psycho-social burden induced by the two-stage intervention in infected hip or knee replacements. All patients were treated with a two-stage exchange and were assessed at three different timepoints regarding their psychological conditions. Our findings suggest that psychological sequelae after treatment of periprosthetic joint infection are clearly underestimated in the literature and psychological correlates and side effects should be further highlighted during the training process of young surgeons.

Synovial Complement Factors in Patients with Periprosthetic Joint Infection after Undergoing Revision Arthroplasty of the Hip or Knee Joint.

The role and diagnostic value of the synovial complement system in patients with low-grade periprosthetic joint infection (PJI) are unclear. We sought to evaluate, for the first time, the usefulness of synovial complement factors in these patients by measuring the individual synovial fluid levels of complement factors (C1q, C3b/iC3b, C4b, C5, C5a, C9, factor B, factor D, factor H, factor I, properdin, and mannose-binding lectin [MBL]). The patients (n = 74) were classified into septic (n = 28) and aseptic (n = 46). Receiver-operator characteristic curves and a multiple regression model to determine the feasibility of a combination of the tested cytokines to determine the infection status were calculated. The synovial fluid levels of C1q, C3b/C3i, C4b, C5, C5a, MBL, and properdin were significantly elevated in the PJI group. The best sensitivity and specificity was found for C1q. The multiple regression models revealed that the combination of C1q, C3b/C3i, C4b, C5, C5a, and MBL was associated with the best sensitivity (83.3%) and specificity (79.2%) for a cutoff value of 0.62 (likelihood ratio: 4.0; area under the curve: 0.853). Nevertheless, only a combined model showed acceptable results. The expression patterns of the complement factors suggested that PJI activates all three pathways of the complement system.

The Performance of a Dithiothreitol-Based Diagnostic System in Diagnosing Periprosthetic Joint Infection Compared to Sonication Fluid Cultures and Tissue Biopsies.

PURPOSE: The aim of this study was to evaluate the performance of a commercially available dithiothreitol (DTT) kit for routine use in diagnosing periprosthetic joint infections (PJIs) in comparison to conventional microbiological tissue specimens and sonication procedures in a maximal care hospital. METHODS: We applied the DTT system in 40 consecutive cases of revision arthroplasty (23 PJIs and 17 aseptic revisions), with an exchange or a removal of components. The hardware components were split between the DTT system and the conventional sonication procedure. At least three tissue biopsies and a joint fluid specimen were sent for microbiological and histopathological analysis. Data was analysed retrospectively to compare between the different methods. RESULTS: Cultures of the DTT fluid showed a sensitivity of 65% and specificity of 100%, as referenced to conventional microbiological cultures. Sonication had better sensitivity (75%) but lower specificity (85%). The categorical agreement of DTT cultures compared to sonication fluid cultures was 78% (31/40). Neither pathogen type, infection duration nor antibiotic pretreatment influenced the accuracy of the DTT, but a low pH in the DTT seemed to be associated with false-negative results. CONCLUSION: DTT was inferior in sensitivity when diagnosing PJIs compared to sonication fluid cultures and tissue biopsies. A low pH in the DTT fluid correlated with false-negative results. Nevertheless, the closed system of the DTT kit avoids contamination and false-positive results, and DTT can be an alternative where sonication is not available.

Outcome of repeated multi-stage arthroplasty with custom-made acetabular implants in patients with severe acetabular bone loss: a case series.

BACKGROUND: Failed reconstruction in cases of severe acetabular bone loss, with or without pelvic discontinuity, in revision total hip arthroplasty (rTHA) remains a great challenge in orthopaedic surgery. The aim of this study was to describe the outcome of a "second" rTHA with "custom-made acetabular components (CMACs)" after a previously failed reconstruction with CMACs. METHODS: 4 patients with severe acetabular bone loss (Paprosky Type IIIB), who required a second rTHA after a previously failed reconstruction with CMAC, due to prosthetic joint infection (PJI), were included in our retrospective study. All prostheses had been constructed on the basis of thin-layer computed-tomography scans of the pelvis. The second rTHA was considered unsuccessful in the event of PJI or aseptic loosening (AL) with need for renewed CMAC explantation. RESULTS: The treatment success rate after second rTHA with a CMAC was 50% (2 of 4). In the successful cases, the visual analogue scale (VAS) score and Harris Hip Score (HHS) after the second rTHA (VAS range 2-4; HHS range 45-58 points) did not differ from those after the first rTHA, before onset of symptoms (VAS: range 2-4; HHS: range 47-55 points). In the failed cases, the second CMACs needed to be explanted due to PJI, with renewed detection of previous pathogens. Patients with treatment failure of the second CMAC had required a higher number of revision surgeries after explantation of the first CMAC than patients with a successful outcome. CONCLUSIONS: In patients with severe acetabular bone loss and previously failed rTHA with CMACs, repeat rTHA with a CMAC may be a solid treatment option for patients with an "uncomplicated" multi-stage procedure, i.e., without persisting infection after explantation of the original CMAC. While the outcome in terms of clinical function does not appear negatively affected by such a "second attempt," the complication rate and risk of reinfection, nonetheless, is high.

Difficult-to-treat pathogens significantly reduce infection resolution in periprosthetic joint infections.

Periprosthetic joint infection (PJI) is a feared complication after arthroplasty. Our hypothesis was that PJI caused by difficult-to-treat (DTT) pathogens has a worse outcome compared with non-DTT PJI. Routine clinical data on 77 consecutive patients with confirmed PJI treated with 2-stage exchange arthroplasty were placed in DTT and non-DTT PJI groups and analyzed. The main outcome variable was that the patient was definitively free of infection after 2 years. We found definitive infection resolution in 31 patients in the DTT group (68.9%) and 28 patients (87.5%) in the non-DTT group (P < 0.05). The necessity for revision surgery until assumed resolution of infection was significantly more frequent in the DTT group with 4.72 ± 3.03 operations versus 2.41 ± 3.02 operations in the non-DTT group (P < 0.05). PJI caused by DTT bacteria is associated with significantly higher numbers of revision operations and significantly inferior definitive infection resolution.

The Influence of Iodine-Impregnated Incision Drapes on the Bacterial Contamination of Scalpel Blades in Joint Arthroplasty.

BACKGROUND: Prosthetic joint infections (PJI) are a disastrous and feared complication in arthroplasty. Over the past decades, surgeons have tried to lower infection rates through all sorts of improvements. At present, it is impossible to reduce the risk to zero. As the contamination of surgical instruments and the surgical field has been identified as a remaining gap prone for infection, scalpel blades among others have become a focal point of several studies. This study is the first to compare the effect of adhesive incision drapes on contamination rates of scalpel blades in primary arthroplasty of the hip and knee. METHODS: A total of 344 microbiologic blade culture results from 2 study groups with and without drape usage and 1 group with known PJI were analyzed and compared to histopathologic and microbiologic tissue results. RESULTS: In 78% of all positive cultures, the bacteria were part of the local skin flora. The contamination rate for the skin blades with a drape was 3.81% vs 12.19% without drape usage. A significant difference was determined between positive skin blade culture results incision drape usage (P = .031). The different pathogens likely responsible for the PJI correlated with the deep blade cultures (P ≤ .01). The overall contamination rate of surgical blades (1.37%) is comparatively low to the results obtained from other surgical equipment in literature. None of those blade-positive patients developed a surgical site infection during 12-month follow-up. CONCLUSION: Iodine-impregnated incision drapes are able to reduce surgical skin blade contamination. Further studies may be needed to assess the relationship between blade contamination and surgical site infections.

The use of negative pressure wound therapy increases failure rate in debridement and implant retention for acute prosthetic joint infection.

BACKGROUND: To date only scanty data exist regarding the effect of failed debridement, antibiotics, irrigation and retention of the prostheses (DAIR) and negative pressure wound therapy (NPWT) on the outcome of a subsequent exchange arthroplasty. OBJECTIVE: The objective of this study was to determine the success rate of a two- or multi-stage procedure after initial failed DAIR/NPWT in patients with an acute periprosthetic joint infection (PJI) and to evaluate the influence of possible risk factors for treatment failure. METHODS: Nineteen consecutive patients with a persisting PJI and ongoing NPWT after treatment of an acute PJI with DAIR of the hip or knee joint from October 2010 to June 2017 were included. All patients were treated according to a structured treatment algorithm after referral to our hospital. The endpoint was a successful reimplantation with absence of signs of infection two years after replantation ("replantation group") or treatment failure ("treatment failure group") in terms of a permanent girdlestone arthroplasty, fistula, amputation or death. A risk factor analysis was performed between the two groups. RESULTS: Explantation was performed in 15 cases, amputation in one case, and DAIR/establishment of a fistula in three cases. The treatment success rate after reimplantation in terms of "definitively free of infection" two years after surgery according to Laffer was 36.85% (seven out of 19 patients). Statistical analysis revealed the number of surgeries until wound consolidation (p= 0.007), number of detected bacterial strains (p= 0.041), a polymicrobial PJI (p= 0.041) and detection of a difficult-to-treat organism (p= 0.005) as factors associated with treatment failure. After failed DAIR/NPWT we could detect a significant higher number of different bacterial strains (p= 0.001). CONCLUSIONS: The treatment success rate after failed DAIR and NPWT with 36% is low and associated with a high treatment failure rate (permanent girdlestone arthroplasty, fistula or amputation, death). Thus, the definition of risk factors is crucial. We found that the number of revisions until wound consolidation, a polymicrobial PJI and detection of a difficult-to-treat organisms were risk factors for treatment failure. Furthermore, after failed DAIR/NPWT we could detect a significant higher number of different bacterial strains, with a possible adverse effect on a consecutive exchange.

Calculated parenteral initial treatment of bacterial infections: Bone and joint infections.

This is the 10th chapter of the guideline "Calculated initial parenteral treatment of bacterial infections in adults - update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. This chapter deals with bacterial Infections of bones, joints and prosthetic joints. One of the most pressing points is that after an initial empirical therapy a targeted antimicrobial which penetrates well to the point of infection and is tolerated well over the usually long duration of the therapy is chosen.

Recurrent mucocutaneous infections caused by PVL-positive Staphylococcus aureus strains: a challenge in clinical practice.

BACKGROUND: Recurrent mucocutaneous infections caused by PVL-positive Staphylococcus (S.) aureus strains represent an increasing problem in Germany. Although there have been several outbreaks at day care centers and in urban communities in recent years, there are currently no diagnostic algorithms or treatment recommendations for these particular infections in Germany. METHODS: We performed a literature search in the PubMed/MEDLINE database with the goal of developing an algorithm for diagnosis and treatment of these infections. National and international recommendations were also considered. RESULTS: Panton-Valentine leukocidin (PVL) is a pore-forming protein produced by certain S. aureus strains. Both methicillin-susceptible (MSSA) and methicillin-resistant S. aureus (MRSA) strains may carry the lukS-lukF gene responsible for PVL production. The clinical presentation of infections caused by PVL-positive S. aureus ranges from isolated recurrent abscesses to extensive furunculosis. Despite adequate treatment of primary infections, approximately 40 % of patients develop recurrent disease. The choice of treatment regimen is guided by the clinical presentation of the infection. In addition, some scientific literature recommends bacteriological screening of patients and their contacts, followed by decolonization of affected individuals. CONCLUSIONS: The present article focuses on the pathogenesis and risk factors of recurrent mucocutaneous infections caused by PVL-positive S. aureus strains and proposes a diagnostic and therapeutic algorithm for optimal patient care.