Posts filed under ‘FIEBRE en el POSTOPERATORIO’
Culture of Bone Biopsy Specimens Overestimates Rate of Residual Osteomyelitis After Toe or Forefoot Amputation.
J Bone Joint Surg Am. September 5, 2018 V.100 N.17 P.1448-1454.
Mijuskovic B1, Kuehl R1, Widmer AF1, Jundt G1, Frei R1, Gürke L1, Wolff T1.
Abstract
BACKGROUND:
Guidelines recommend both histological analysis and culture for definite diagnosis of osteomyelitis. It is not clear if histological and culture criteria can be used interchangeably in the clinical scenario of toe amputation. We therefore prospectively compared the results of intraoperative culture and those of histological examination in this setting.
METHODS:
Consecutive patients requiring toe or forefoot amputation at the University Hospital Basel during a 2-year period were included in the study. Biopsy specimens from the residual bone were cultured according to microbiological standards. Histological analysis was performed using standardized criteria for osteomyelitis. Clinical outcomes were assessed retrospectively via chart review.
RESULTS:
Of 51 patients included in the study, 33 (65%) had a positive culture of residual bone and 14 (27%) showed histological signs of osteomyelitis. A negative histological result but a positive culture was found for 21 (41%) of the patients, suggesting that culture has a high false-positive rate if histological analysis is used as the reference to rule out osteomyelitis. The recommended criteria of both positive histological findings and positive culture were fulfilled by 12 (24%) of the 51 patients.
CONCLUSIONS:
Positive cultures of residual bone after forefoot or toe amputation overestimate the true rate of osteomyelitis as defined by histological analysis, presumably because of contamination from soft tissue at the time of surgery. Additional studies are needed to evaluate the indications for, and the duration of, antibiotic treatment according to these findings.
CLINICAL RELEVANCE:
Our results cast doubt on the strategy of relying solely on culture of bone biopsy specimens when deciding whether antibiotic treatment for osteomyelitis is necessary after toe or forefoot amputation.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6125752/pdf/jbjsam-100-1448.pdf
Incidence and risk factors for infection in spine surgery: A prospective multicenter study of 1764 instrumented spinal procedures
American Journal of Infection Control January 2018 V.46 N.1 P.8-13
Wenfei Gu, Laiyong Tu, Zhiquan Liang, Zhenbin Wang, Kahaer Aikenmu, Ge Chu, Enfeng Zhang, Jiang Zhao
Background
Surgical site infection (SSI) is a common complication in spinal surgery, imposing a high burden on patients and society. However, information about its characteristics and related risk factors is limited. We designed this prospective, multicenter study to address this issue.
Methods
From January 2015 through February 2016, a total of 1764 patients who had spinal trauma or degenerative spinal diseases were treated with instrumented surgeries and followed up for 1 year with complete data. Data on all patients were abstracted from electronic medical records, and SSIs were prospectively inspected and diagnosed by surgeons in our department. Any disagreement among them was settled by the leader of this study. SPSS 19.0 was used to perform the analyses.
Results
A total of 58 patients (3.3%, 58 of 1764) developed SSI; 1.1% had deep SSI, and 2.2% had superficial SSI. Of these, 60.6% (21 of 33) had a polymicrobial cause. Most of them (51 of 58) occurred during hospitalization. The median occurrence time was 3 days after operation (range: 1–123 days). SSI significantly prolonged hospital stays, by 9.3 days on average. The univariate analysis revealed reason for surgery as the only significant risk factor. The multivariate analysis, however, revealed 8 significant risk factors, including higher BMI, surgical site (cervical), surgical approach (posterior), surgery performed in summer, reasons for surgery (degenerative disease), autograft for fusion and fixation, and higher preoperative platelet level.
Conclusion
Identification of these risk factors aids in stratifying preoperative risk to reduce SSI incidence. In addition, the results could be used in counseling patients and their families during the consent process.
FULL TEXT
https://www.ajicjournal.org/article/S0196-6553(17)31100-8/fulltext
https://www.ajicjournal.org/article/S0196-6553(17)31100-8/pdf
The Leukocyte Esterase Test Strip Is a Poor Rule-Out Test for Periprosthetic Joint Infection
Journal of Arthroplasty August 2018 V.33 N.8 P.2571–2574
Carl A. Deirmengian, Lihua Liang, John P. Rosenberger, Tony R. Joaquim, Martin R. Gould, Patrick A. Citrano, Keith W. Kardos
Background
The urinary leukocyte esterase (LE) test strip has been suggested as a good screening test for periprosthetic joint infection (PJI). The purpose of this study is to compare the diagnostic profile of LE assays from different manufacturers and determine whether the LE test strip is a good rule-out test.
Methods
Synovial fluid samples (N = 344), sent to 1 laboratory for PJI testing, were used in this prospective study. Four different tests for synovial fluid LE were simultaneously evaluated for their performance in detecting white blood cell (WBC) positive samples (>3000 cells/µL).
Results
Both neutrophil elastase immunoassays demonstrated greater sensitivity than urinary LE test strips (92.0% and 90.8% vs 72.4% and 80.3%; all P < 0.011). Fifty-three percent of false-negative urinary LE test strip results clearly missed the presence of elevated levels of synovial fluid LE. Invalid urinary LE test strip results were 4-fold more likely among WBC (+) compared with WBC (−) samples (27.0% vs 6.8%; P < 0.0001). The combined failure to detect an elevated WBC count, because of either false-negative or invalid results, was 47.1% and 41.4% for the Roche and Siemens test strips, respectively.
Conclusions
This study agrees with the existing literature demonstrating that the LE test strips are among the lowest sensitivity tests for PJI. The urinary LE tests strips should not be used to rule-out PJI, as they often fail to detect abundant levels of LE in synovial fluid. Instead, it is more appropriate to use the (++) LE test strip result as a secondary confirmatory rule-in test for PJI because of its high specificity.
FULL TEXT
https://www.arthroplastyjournal.org/article/S0883-5403(18)30243-2/fulltext
https://www.arthroplastyjournal.org/article/S0883-5403(18)30243-2/pdf
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.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6105475/pdf/12178_2018_Article_9499.pdf
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.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5434347/pdf/WJO-8-400.pdf
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.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5213924/pdf/11999_2016_Article_4906.pdf
Current Recommendations for the Diagnosis of Acute and Chronic PJI for Hip and Knee-Cell Counts, Alpha-Defensin, Leukocyte Esterase, Next-generation Sequencing.
Curr Rev Musculoskelet Med. September 2018 V.11 N.3 P.428-438.
Goswami K1, Parvizi J1, Maxwell Courtney P2.
Author information
1 The Rothman Institute at Thomas Jefferson University, 125 S 9th St. Ste 1000, Philadelphia, PA, 19107, USA.
2 The Rothman Institute at Thomas Jefferson University, 125 S 9th St. Ste 1000, Philadelphia, PA, 19107, USA. Max.Courtney@rothmaninstitute.com .
Abstract
PURPOSE OF REVIEW:
Despite significant progress in recent years, the diagnosis of periprosthetic joint infection (PJI) remains a challenge and no gold standard test exists. A combination of serological, synovial, microbiological, histological, and radiological investigations is performed that are expensive, often invasive, and imperfect. Novel biomarkers and molecular methods have shown promise in recent years. The purpose of this review is to provide an update about the diagnostic recommendations for PJI and cover a selection of emerging diagnostic tools.
RECENT FINDINGS:
Recent literature highlights a new evidence-based definition for diagnosing hip and knee PJI that shows excellent performance on formal external multi-institutional validation. There is also increasing evidence to support the measurement of selected biomarkers in serum and synovial fluid, such as alpha-defensin, D-dimer, and interleukin-6. Finally, the emerging utility of next-generation sequencing for pathogen identification is discussed. In summary, we describe current recommendations and emerging tests for the diagnosis of PJI. Residual limitations and directions for future research are also discussed.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6105482/pdf/12178_2018_Article_9513.pdf
