Archive for August, 2019

Single-Dose Perioperative Antibiotics Do Not Increase the Risk of Surgical Site Infection in Unicompartmental Knee Arthroplasty

Journal of Arthroplasty July 2019 V.34 Supplement S327–S330


Unicompartmental knee arthroplasty (UKA) is commonly performed as an outpatient procedure. To facilitate this process, a single-dose intravenous (IV) perioperative antibiotic administration is required compared to 24-hour IV antibiotic dosing schedules that are typical of most inpatient arthroplasty procedures. There is a paucity of literature to guide surgeons on the safety of single-dose perioperative antibiotic administration for arthroplasty procedures, particularly those that will be performed in the outpatient setting. The purpose of this study is to evaluate a large series of UKA performed with single-dose vs 24-hour IV antibiotic coverage to determine the impact on risk for surgical site infection (SSI).


All UKA cases were evaluated from 2007 to 2017 performed by a single surgeon at an academic institution. There were 296 UKAs in the cohort: 40 were outpatient procedures receiving single-dose antibiotics and 256 were inpatient procedures receiving 24-hour antibiotics. No patients were prescribed adjuvant oral antibiotics. Mean age was 64 years, 50% were female, mean body mass index was 32 kg/m2, and mean follow-up was 4.1 years (range 1.0-10.4). Perioperative antibiotic regimen was evaluated and SSI, defined as occurring within 1 year of surgery, was abstracted through a prospective total joint registry and manual chart review.


SSI occurred in 2 of 296 cases (0.7%) in the entire cohort, 2 of 256 inpatient UKAs (0.8%), and 0 of 40 outpatient UKAs (0%) (P = 1.00). One SSI was a deep infection occurring 6 weeks postoperatively that required 2-stage exchange and conversion to total knee arthroplasty. The other was a superficial infection treated with 2 weeks of oral antibiotics.


This study demonstrates a low SSI risk (0.8% or less) following UKA with both single-dose and 24-hour IV antibiotics. Administering single-dose perioperative antibiotics is safe for UKA, which should alleviate that potential concern for outpatient surgery.



August 30, 2019 at 4:15 pm

Traditional Laboratory Markers Hold Low Diagnostic Utility for Immunosuppressed Patients With Periprosthetic Joint Infections

Journal of Arthroplasty July 2019 V.34 N.7 P.1441–1445


Although predictive laboratory markers and cutoffs for immunocompetent patients are well-studied, similar reference ranges and decision thresholds for immunosuppressed patients are less understood. We investigated the utility of typical laboratory markers in immunosuppressed patients undergoing aspiration of a prosthetic hip or knee joint.


A retrospective review of adult patients with an immunosuppressed state that underwent primary and revision total joint arthroplasty with a subsequent infection at our tertiary, academic institution was conducted. Infection was defined by Musculoskeletal Infection Society criteria. A multivariable analysis was used to identify independent factors associated with acute (<90 days) and chronic (>90 days) infection. Area under the receiver-operator curve (AUC) was used to determine the best supported laboratory cut points for identifying infection.


We identified 90 patients with immunosuppression states totaling 172 aspirations. Mean follow-up from aspiration was 33 months. In a multivariate analysis, only synovial fluid cell count and synovial percent neutrophils were found to be independently correlated with both acute and chronic infection. A synovial fluid cell count cutoff value of 5679 nucleated cells/mm3 maximized the AUC (0.839) for predicting acute infection, while a synovial fluid cell count cutoff value of 1293 nucleated cells/mm3 maximized the AUC (0.931) for predicting chronic infection.


Physicians should be aware of lower levels of synovial nucleated cell count and percentage of neutrophils in prosthetic joint infections of the hip or knee in patients with immunosuppression. Further investigation is necessary to identify the best means of diagnosing periprosthetic joint infection in this patient population.



August 30, 2019 at 4:10 pm

The Presence of Sinus Tract Adversely Affects the Outcome of Treatment of Periprosthetic Joint Infections

Journal of Arthroplasty June 2019 V.34 N.6 P.1227-1232


A sinus tract may be encountered in patients with periprosthetic joint infection (PJI) and constitutes a major criterion for diagnosis. The aim of this study is to identify associated factors for the presence of sinus tract and outcome of 2-stage exchange arthroplasty in these patients.


We retrospectively reviewed all patients with PJI following hip and knee arthroplasty from 2000 to 2017. Of them, 161 patients with a sinus tract had a minimum follow-up of 1 year following 2-stage exchange arthroplasty. These patients were matched 1:2 with those without sinus tract by using propensity score matching. Treatment success was assessed using the modified Delphi criteria. A multiple logistic regression analysis was performed to determine the effect of sinus tract on the outcome and associated factors for the presence of sinus tract.


Factors significantly associated with sinus tract included smoking (odds ratio [OR] = 1.83), hypothyroidism (OR = 1.62), hypoalbuminemia (OR = 1.52), hip joint involvement (OR = 1.43), and prior revision surgery (OR = 1.37). Patients with sinus tract had a significantly higher rate of failure compared to those without sinus tract (OR = 2.94).


This study demonstrates that the presence of sinus tract in patients with PJI adversely affects the outcome of treatment of these patients. The presence of sinus tract may be a proxy for other issues such as poor periarticular soft tissue, the poor nutritional status of the host, and multiple prior operations. These findings need to be borne in mind when treating patients with PJI and a concomitant sinus tract.



August 30, 2019 at 4:08 pm

Synovial Fluid Viscosity Test is Promising for the Diagnosis of Periprosthetic Joint Infection

Journal of Arthroplasty June 2019 V.34 N.6 P.1197-1200


So far there is no “gold standard” test for the diagnosis of periprosthetic joint infection (PJI), compelling clinicians to rely on several serological and synovial fluid tests with no 100% accuracy. Synovial fluid viscosity is one of the parameters defining the rheology properties of synovial fluid. We hypothesized that patients with PJI may have a different level of synovial fluid viscosity and aimed to investigate the sensitivity and specificity of synovial fluid viscosity in detecting PJI.


This prospective study was initiated to enroll patients undergoing primary and revision arthroplasty. Our cohort consisted of 45 patients undergoing revision for PJI (n = 15), revision for aseptic failure (n = 15), and primary arthroplasty (n = 15). PJI was defined using the Musculoskeletal Infection Society criteria. In all patients, synovial fluid viscosity, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and plasma d-dimer levels were measured preoperatively.


The synovial fluid viscosity level was significantly lower (P = .0011) in patients with PJI (7.93 mPa·s, range 3.0-15.0) than in patients with aseptic failure (13.11 mPa·s, range 6.3-20.4). Using Youden’s index, 11.80 mPa·s was determined as the optimal threshold value for synovial fluid viscosity for the diagnosis of PJI. Synovial fluid viscosity outperformed CRP, ESR, and plasma d-dimer, with a sensitivity of 93.33% and a specificity of 66.67%.


Synovial fluid viscosity seems to be on the same level of accuracy with CRP, ESR, and d-dimer regarding PJI detection and to be a promising marker for the diagnosis of PJI.



August 30, 2019 at 4:05 pm

Age-associated changes in the impact of sex steroids on influenza vaccine responses in males and females 

npj Vaccines 2019 V.4 N.29


Vaccine-induced immunity declines with age, which may differ between males and females. Using human sera collected before and 21 days after receipt of the monovalent A/Cal/09 H1N1 vaccine, we evaluated cytokine and antibody responses in adult (18–45 years) and aged (65+ years) individuals. After vaccination, adult females developed greater IL-6 and antibody responses than either adult males or aged females, with female antibody responses being positively associated with concentrations of estradiol. To test whether protection against influenza virus challenge was greater in females than males, we primed and boosted adult (8–10 weeks) and aged (68–70 weeks) male and female mice with an inactivated A/Cal/09 H1N1 vaccine or no vaccine and challenged with a drift variant A/Cal/09 virus. As compared with unvaccinated mice, vaccinated adult, but not aged, mice experienced less morbidity and better pulmonary viral clearance following challenge, regardless of sex. Vaccinated adult female mice developed antibody responses that were of greater quantity and quality and more protective than vaccinated adult males. Sex differences in vaccine efficacy diminished with age in mice. To determine the role of sex steroids in vaccine-induced immune responses, adult mice were gonadectomized and hormones (estradiol in females and testosterone in males) were replaced in subsets of animals before vaccination. Vaccine-induced antibody responses were increased in females by estradiol and decreased in males by testosterone. The benefit of elevated estradiol on antibody responses and protection against influenza in females is diminished with age in both mice and humans.


August 30, 2019 at 7:49 am

Clinical Klebsiella pneumoniae Isolate with Three Carbapenem Resistance Genes Associated with Urology Procedures – King County, Washington, 2018.

MMWR Morb Mortal Wkly Rep. 2019 Aug 2;68(30):667-668.

Vannice K, Benoliel E, Kauber K, Brostrom-Smith C, Montgomery P, Kay M, Walters M, Tran M, D’Angeli M, Duchin J.


August 29, 2019 at 6:12 pm

Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of Americaa.

Clin Infect Dis. March 21, 2019 pii: ciy1121. doi: 10.1093/cid/ciy1121. [Epub ahead of print]

Nicolle LE1, Gupta K2, Bradley SF3, Colgan R4, DeMuri GP5, Drekonja D6, Eckert LO7, Geerlings SE8, Köves B9, Hooton TM10, Juthani-Mehta M11, Knight SL12, Saint S13, Schaeffer AJ14, Trautner B15, Wullt B16, Siemieniuk R17.

Author information

1 Department of Internal Medicine, School of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.

2 Division of Infectious Diseases, Veterans Affairs Boston Healthcare System and Boston University School of Medicine, West Roxbury, Massachusetts.

3 Division of Infectious Diseases, University of Michigan, Ann Arbor.

4 Department of Family and Community Medicine, University of Maryland, Baltimore.

5 Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison.

6 Division of Infectious Diseases, University of Minnesota, Minneapolis.

7 Department of Obstetrics and Gynecology and Department of Global Health, University of Washington, Seattle.

8 Department of Internal Medicine, Amsterdam University Medical Center, The Netherlands.

9 Department of Urology, South Pest Teaching Hospital, Budapest, Hungary.

10 Division of Infectious Diseases, University of Miami, Florida.

11 Division of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut.

12 Library and Knowledge Services, National Jewish Health, Denver, Colorado.

13 Department of Internal Medicine, Veterans Affairs Ann Arbor and University of Michigan, Ann Arbor.

14 Department of Urology, Northwestern University, Chicago, Illinois.

15 Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas.

16 Division of Microbiology, Immunology and Glycobiology, Lund, Sweden.

17 Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.


Asymptomatic bacteriuria (ASB) is a common finding in many populations, including healthy women and persons with underlying urologic abnormalities. The 2005 guideline from the Infectious Diseases Society of America recommended that ASB should be screened for and treated only in pregnant women or in an individual prior to undergoing invasive urologic procedures. Treatment was not recommended for healthy women; older women or men; or persons with diabetes, indwelling catheters, or spinal cord injury. The guideline did not address children and some adult populations, including patients with neutropenia, solid organ transplants, and nonurologic surgery. In the years since the publication of the guideline, further information relevant to ASB has become available. In addition, antimicrobial treatment of ASB has been recognized as an important contributor to inappropriate antimicrobial use, which promotes emergence of antimicrobial resistance. The current guideline updates the recommendations of the 2005 guideline, includes new recommendations for populations not previously addressed, and, where relevant, addresses the interpretation of nonlocalizing clinical symptoms in populations with a high prevalence of ASB.



August 29, 2019 at 6:10 pm

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