Archive for September 2, 2018

The Role of One-Stage Exchange for Prosthetic Joint Infection.

Curr Rev Musculoskelet Med. July 9, 2018

Rowan FE1,2, Donaldson MJ3,4, Pietrzak JR3,4, Haddad FS3,4.

Author information

1 Department of Orthopaedic Surgery, University College London Hospital, 250 Euston Road, London, NW1 2PG, UK. fiachrarowan@rcsi.ie.

2 The Princess Grace Hospital, 42-52 Nottingham Place, Marylebone, London, W1U 5NY, UK. fiachrarowan@rcsi.ie.

3 Department of Orthopaedic Surgery, University College London Hospital, 250 Euston Road, London, NW1 2PG, UK.

4 The Princess Grace Hospital, 42-52 Nottingham Place, Marylebone, London, W1U 5NY, UK.

Abstract

PURPOSE OF REVIEW:

In an era of increasing numbers of hip and knee replacements, strategies to manage prosthetic joint infection (PJI) that are effective at infection control with good patient-reported outcomes and cost containment for health systems are needed. Interest in single-stage exchange for PJI is rising and we assess evidence from the last 5 years related to this treatment strategy.

RECENT FINDINGS:

Only five series for total knee replacement and ten series for total hip replacement have been reported in the last five years. More review articles and opinion pieces have been written. Reinfection rates in these recent studies range from 0 to 65%, but a meta-analysis and systematic review of all studies showed a reinfection rate of 7.6% (95% CI 3.4-13.1) and 8.8% (95% CI 7.2-10.6) for single-stage and two-stage revisions respectively. There is emerging evidence to support single-stage revision in the setting of significant bony deficiency and atypical PJIs such as fungal infections. Prospective randomised studies are recruiting and are necessary to guide the direction of single-stage revision selection criteria. The onus of surgical excellence in mechanical removal of implants, necrotic tissue, and biofilms lies with the arthroplasty surgeon and must remain the cornerstone of treatment. Single-stage revision may be considered the first-line treatment for all PJIs unless the organism is unknown, the patient is systemically septic, or there is a poor tissue envelope.

PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6105475/pdf/12178_2018_Article_9499.pdf

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September 2, 2018 at 7:02 pm

Predicting lower limb periprosthetic joint infections: A review of risk factors and their classification.

World J Orthop. May 18, 2017 V.8 N.5 P.400-411.

George DA1, Drago L1, Scarponi S1, Gallazzi E1, Haddad FS1, Romano CL1.

Author information

1 David A George, Fares S Haddad, Department of Trauma and Orthopaedics, University College London Hospitals, London NW1 2BU, United Kingdom.

Abstract

AIM:

To undertook a systematic review to determine factors that increase a patient’s risk of developing lower limb periprosthetic joint infections (PJI).

METHODS:

This systematic review included full-text studies that reviewed risk factors of developing either a hip or knee PJI following a primary arthroplasty published from January 1998 to November 2016. A variety of keywords were used to identify studies through international databases referencing hip arthroplasty, knee arthroplasty, infection, and risk factors. Studies were only included if they included greater than 20 patients in their study cohort, and there was clear documentation of the statistical parameter used; specifically P-value, hazard ratio, relative risk, or/and odds ratio (OR). Furthermore a quality assessment criteria for the individual studies was undertaken to evaluate the presence of record and reporting bias.

RESULTS:

Twenty-seven original studies reviewing risk factors relating to primary total hip and knee arthroplasty infections were included. Four studies (14.8%) reviewed PJI of the hip, 3 (11.21%) of the knee, and 20 (74.1%) reviewed both joints. Nineteen studies (70.4%) were retrospective and 8 (29.6%) prospective. Record bias was identified in the majority of studies (66.7%). The definition of PJI varied amongst the studies but there was a general consensus to define infection by previously validated methods. The most significant risks were the use of preoperative high dose steroids (OR = 21.0, 95%CI: 3.5-127.2, P < 0.001), a BMI above 50 (OR = 18.3, P < 0.001), tobacco use (OR = 12.76, 95%CI: 2.47-66.16, P = 0.017), body mass index below 20 (OR = 6.00, 95%CI: 1.2-30.9, P = 0.033), diabetes (OR = 5.47, 95%CI: 1.77-16.97, P = 0.003), and coronary artery disease (OR = 5.10, 95%CI: 1.3-19.8, P = 0.017).

CONCLUSION:

We have highlighted the need for the provider to optimise modifiable risk factors, and develop strategies to limit the impact of non-modifiable factors.

PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5434347/pdf/WJO-8-400.pdf

 

September 2, 2018 at 7:00 pm

How Reliable Is the Alpha-defensin Immunoassay Test for Diagnosing Periprosthetic Joint Infection? A Prospective Study.

Clin Orthop Relat Res. February 2017 V.475 N.2 P.408-415.

Bonanzinga T1, Zahar A2, Dütsch M1, Lausmann C1, Kendoff D3, Gehrke T1.

Author information

1 HELIOS ENDO Klinik, Holstenstrasse 2, 22767, Hamburg, Germany.

2 HELIOS ENDO Klinik, Holstenstrasse 2, 22767, Hamburg, Germany. akos.zahar@helios-kliniken.de.

3 HELIOS Klinik Berlin-Buch, Berlin, Germany.

Abstract

BACKGROUND:

A key issue in the treatment of periprosthetic joint infection (PJI) is the correct diagnosis. The main problem is lack of diagnostic tools able to diagnose a PJI with high accuracy. Alpha-defensin has been proposed as a possible solution, but in the current literature, there is a lack of independent validation.

QUESTIONS/PURPOSES:

We performed a prospective study to determine (1) what is the sensitivity, specificity, and positive and the negative predictive values of the alpha-defensin immunoassay test in diagnosing PJI; and (2) which clinical features may be responsible for false-positive and false-negative results?

METHODS:

Preoperative aspiration was performed in all patients presenting with a painful hip/knee arthroplasty, including both primary and revision implants. Metallosis, other inflammatory comorbidities, and previous/concomitant antibiotic therapy were not considered as exclusion criteria. An inadequate amount of synovial fluid for culture was an exclusion criterion. A total of 156 patients (65 knees, 91 hips) were included in this prospective study. At the time of revision, synovial fluid samples were taken to perform the alpha-defensin assay. During surgical débridement of tissue, samples for cultures and histologic evaluation were taken, and samples were cultured until positive or until negative at 14 days. A diagnosis of PJI was confirmed in 29 patients according to the International Consensus Group on PJI.

RESULTS:

The sensitivity of the alpha-defensin immunoassay was 97% (95% confidence interval [CI], 92%-99%), the specificity was 97% (95% CI, 92%-99%), the positive predictive value was 88% (95% CI, 81%-92%), and the negative predictive value was 99% (95% CI, 96%-99%). Among four false-positive patients, two had metallosis and one had polyethylene wear. The false-negative case presented with a draining sinus, and intraoperative cultures were also negative.

CONCLUSIONS:

Alpha-defensin assay appears to be a reliable test, but followup evaluation is needed to estimate longer term performance of the test. The authors believe that alpha-defensin has demonstrated itself to be sufficiently robust that PJI diagnostic criteria now should include this test. Future studies are needed to compare the differences among the diagnostic capability of the available tests, in particular when metallosis is present, because metallosis may predispose the test to a false-positive result.

LEVEL OF EVIDENCE:

Level I, diagnostic study.

PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5213924/pdf/11999_2016_Article_4906.pdf

September 2, 2018 at 6:58 pm

Longitudinal Assessment of Multidrug-Resistant Organisms in Newly Admitted Nursing Facility Patients: Implications for an Evolving Population

Clinical Infectious Diseases September 15, 2018 V.67 N.6 P.837–844

Lona Mody; Betsy Foxman; Suzanne Bradley; Sara McNamara; Bonnie Lansing …

We sampled 651 recently admitted nursing facility patients and collected clinical and microbiological data over 1629 visits. We found that more than 57% were colonized with 1 or more multidrug-resistant organisms on enrollment, and 56% were colonized at discharge from the facility.

Background

The spread of multidrug-resistant organisms (MDROs) is a global concern, and much about transmission in healthcare systems remains unknown. To reduce hospital stays, nursing facilities (NFs) have increasingly assumed care of post–acute populations. We estimate the prevalence of MDRO colonization in NF patients on enrollment and discharge to community settings, risk factors for colonization, and rates of acquiring MDROs during the stay.

Methods

We conducted a prospective, longitudinal cohort study of newly admitted patients in 6 NFs in southeast Michigan using active microbial surveillance of multiple anatomic sites sampled at enrollment, days 14 and 30, and monthly thereafter for up to 6 months.

Results

We enrolled 651 patients and collected 7526 samples over 1629 visits, with an average of 29 days of follow-up per participant. Nearly all participants were admitted for post–acute care (95%). More than half (56.8%) were colonized with MDROs at enrollment: methicillin-resistant Staphylococcus aureus (MRSA), 16.1%; vancomycin-resistant enterococci (VRE), 33.2%; and resistant gram-negative bacilli (R-GNB), 32.0%. Risk factors for colonization at enrollment included prolonged hospitalization (>14 days), functional disability, antibiotic use, or device use. Rates per 1000 patient-days of acquiring a new MDRO were MRSA, 3.4; VRE, 8.2; and R-GNB, 13.6. MDRO colonization at discharge was similar to that at enrollment (56.4%): MRSA, 18.4%; VRE, 30.3%; and R-GNB, 33.6%.

Conclusions

Short-stay NF patients exhibit a high prevalence of MDROs near the time of admission, as well as at discharge, and may serve as a reservoir for spread in other healthcare settings. Future interventions to reduce MDROs should specifically target this population.

FULL TEXT

https://academic.oup.com/cid/article/67/6/837/4965240

PDF (CLIC en PDF)

September 2, 2018 at 5:39 pm

A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2018 Update by the Infectious Diseases Society of America and the American Society for Microbiology

Clinical Infectious Diseases September 15, 2018 V.67 N.6 P.813–816

IDSA GUIDELINE

J Michael Miller; Matthew J Binnicker; Sheldon Campbell; Karen C Carroll; Kimberle C Chapin …

The critical nature of the microbiology laboratory in infectious disease diagnosis calls for a close, positive working relationship between the physician/advanced practice provider and the microbiologists who provide enormous value to the healthcare team.

This document, developed by experts in laboratory and adult and pediatric clinical medicine, provides information on which tests are valuable and in which contexts, and on tests that add little or no value for diagnostic decisions.

This document presents a system-based approach rather than specimen-based approach, and includes bloodstream and cardiovascular system infections, central nervous system infections, ocular infections, soft tissue infections of the head and neck, upper and lower respiratory infections, infections of the gastrointestinal tract, intra-abdominal infections, bone and joint infections, urinary tract infections, genital infections, and other skin and soft tissue infections; or into etiologic agent groups, including arthropod-borne infections, viral syndromes, and blood and tissue parasite infections.

Each section contains introductory concepts, a summary of key points, and detailed tables that list suspected agents; the most reliable tests to order; the samples (and volumes) to collect in order of preference; specimen transport devices, procedures, times, and temperatures; and detailed notes on specific issues regarding the test methods, such as when tests are likely to require a specialized laboratory or have prolonged turnaround times.

In addition, the pediatric needs of specimen management are also emphasized. There is intentional redundancy among the tables and sections, as many agents and assay choices overlap.

The document is intended to serve as a guidance for physicians in choosing tests that will aid them to quickly and accurately diagnose infectious diseases in their patients.

FULL TEXT

https://academic.oup.com/cid/article/67/6/813/5088024

PDF (CLIC en PDF)

September 2, 2018 at 10:40 am

Effects of Pre-exposure Prophylaxis for the Prevention of Human Immunodeficiency Virus Infection on Sexual Risk Behavior in Men Who Have Sex With Men: A Systematic Review and Meta-analysis

Clinical Infectious Diseases September 1, 2018 V.67 N.5 P.676–686

EDITOR’S CHOICE

Michael W Traeger; Sophia E Schroeder; Edwina J Wright; Margaret E Hellard; Vincent J Cornelisse..

This systematic review and meta-analysis of 17 open-label studies published to 2017 found that daily HIV pre-exposure prophylaxis use among men who have sex with men is associated with increased sexually transmitted infection diagnoses and an increase in condomless sex.

Background

Human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) is effective in reducing HIV risk in men who have sex with men (MSM). However, concerns remain that risk compensation in PrEP users may lead to decreased condom use and increased incidence of sexually transmitted infections (STIs). We assessed the impact of PrEP on sexual risk outcomes in MSM.

Methods

We conducted a systematic review of open-label studies published to August 2017 that reported sexual risk outcomes in the context of daily oral PrEP use in HIV-negative MSM and transgender women. Pooled effect estimates were calculated using random-effects meta-analysis, and a qualitative review and risk of bias assessment were performed.

Results

Sixteen observational studies and 1 open-label trial met selection criteria. Eight studies with a total of 4388 participants reported STI prevalence, and 13 studies with a total of 5008 participants reported change in condom use. Pre-exposure prophylaxis use was associated with a significant increase in rectal chlamydia (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.19–2.13) and an increase in any STI diagnosis (OR, 1.24; 95% CI, .99–1.54). The association of PrEP use with STI diagnoses was stronger in later studies. Most studies showed evidence of an increase in condomless sex among PrEP users.

Conclusion

Findings highlight the importance of efforts to minimize STIs among PrEP users and their sexual partners. Monitoring of risk compensation among MSM in the context of PrEP scale-up is needed to assess the impact of PrEP on the sexual health of MSM and to inform preventive strategies.

FULL TEXT

https://academic.oup.com/cid/article/67/5/676/4917600

PDF (CLIC en PDF)

September 2, 2018 at 10:36 am

Bezlotoxumab for Prevention of Recurrent Clostridium difficile Infection in Patients at Increased Risk for Recurrence

Clinical Infectious Diseases September 1, 2018 V.67 N.5 P.649–656

Dale N Gerding; Ciaran P Kelly; Galia Rahav; Christine Lee; Erik R Dubberke …

Subgroup analyses from MODIFY confirmed that prior Clostridium difficile infection (CDI), age ≥65 years, infection with 027/078/244 strain, compromised immunity, and severe CDI are risk factors for recurrent CDI. Bezlotoxumab reduced CDI recurrence in participants with ≥1 risk factor compared with placebo.

Background

Bezlotoxumab is a human monoclonal antibody against Clostridium difficile toxin B indicated to prevent C. difficile infection (CDI) recurrence (rCDI) in adults at high risk for rCDI. This post hoc analysis of pooled monocolonal antibodies for C.difficile therapy (MODIFY) I/II data assessed bezlotoxumab efficacy in participants with characteristics associated with increased risk for rCDI.

Methods

The analysis population was the modified intent-to-treat population who received bezlotoxumab or placebo (n = 1554) by risk factors for rCDI that were prespecified in the statistical analysis plan: age ≥65 years, history of CDI, compromised immunity, severe CDI, and ribotype 027/078/244. The proportion of participants with rCDI in 12 weeks, fecal microbiota transplant procedures, 30-day all cause and CDI-associated hospital readmissions, and mortality at 30 and 90 days after randomization were presented.

Results

The majority of enrolled participants (75.6%) had ≥1 risk factor; these participants were older and a higher proportion had comorbidities compared with participants with no risk factors. The proportion of placebo participants who experienced rCDI exceeded 30% for each risk factor compared with 20.9% among those without a risk factor, and the rCDI rate increased with the number of risk factors (1 risk factor: 31.3%; ≥3 risk factors: 46.1%). Bezlotoxumab reduced rCDI, fecal microbiota transplants, and CDI-associated 30-day readmissions in participants with risk factors for rCDI.

Conclusions

The risk factors prespecified in the MODIFY statistical analysis plan are appropriate to identify patients at high risk for rCDI. While participants with ≥3 risk factors had the greatest reduction of rCDI with bezlotoxumab, those with 1 or 2 risk factors may also benefit.

Clinical Trials Registration NCT01241552 (MODIFY I) and NCT01513239 (MODIFY II).

FULL TEXT

https://academic.oup.com/cid/article/67/5/649/4925796

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September 2, 2018 at 10:33 am


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