Posts filed under ‘Infecciones sitio quirurgico’

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

 

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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

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.

PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6105482/pdf/12178_2018_Article_9513.pdf

 

 

 

September 1, 2018 at 7:18 pm

Moxifloxacin plus rifampin as an alternative for levofloxacin plus rifampin in the treatment of a prosthetic joint infection with Staphylococcus aureus.

Int J Antimicrob Agents. 2018 Jan;51(1):38-42.                     

Wouthuyzen-Bakker M1, Tornero E2, Morata L3, Nannan Panday PV4, Jutte PC5, Bori G6, Kampinga GA7, Soriano A3.

Author information

1 Department of Internal Medicine / Infectious Diseases, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands. Electronic address:m.wouthuyzen-bakker@umcg.nl.

2 Department of Orthopaedic Surgery, Sant Joan de Déu, Barcelona, Spain.

3 Service of Infectious Diseases, Hospital Clínic, University of Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.

4 Department of Clinical Pharmacy, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.

5 Department of Orthopaedic Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.

6 Department of Orthopaedic Surgery and Traumatology, Hospital Clinic, University of Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.

7 Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.

Abstract

OBJECTIVES:

The combination of a fluoroquinolone with rifampin is one of the cornerstones in the treatment of prosthetic joint infections (PJI) caused by staphylococci. Moxifloxacin is highly active against methicillin-susceptible Staphylococcus aureus (MSSA) and, therefore, is an attractive agent to use. However, several studies reported a lowering in serum moxifloxacin levels when combined with rifampin. The clinical relevance remains unclear. We determined the outcome of patients with early acute PJI caused by MSSA treated with either moxifloxacin/rifampin or levofloxacin/rifampin.

METHODS:

Medical files of patients treated with moxifloxacin/rifampin (University Medical Centre Groningen) or levofloxacin/rifampin (Hospital Clinic Barcelona) were retrospectively reviewed (2005-2015). Treatment failure was defined as the need for revision surgery and/or suppressive therapy, death by infection or a relapse of infection during follow-up.

RESULTS:

Differences in baseline characteristics between the two cohorts were observed, but prognostic parameters for failure, as defined by the KLIC-score (Kidney failure, Liver cirrhosis, Index surgery, C-reactive protein and Cemented prosthesis), were similar in the two groups (2.9 [1.5 SD] for the moxifloxacin group vs. 2.2 [1.2 SD] for the levofloxacin group [P = 0.16]). With a mean follow-up of 50 months (36 SD) in the moxifloxacin group, and 67 months (50 SD) in the levofloxacin group (P = 0.36), treatment was successful in 89% vs. 87.5%, respectively (P = 0.89). None of the failures in the moxifloxacin group were due to rifampin- or moxifloxacin-resistant S. aureus strains.

CONCLUSION:

Our data indicate that moxifloxacin combined with rifampin is as clinically effective as levofloxacin/rifampin for early acute PJI caused by MSSA.

PDF

https://www.ijaaonline.com/article/S0924-8579(17)30210-8/pdf

July 31, 2018 at 6:52 pm

The Effect of Preoperative Antimicrobial Prophylaxis on Intraoperative Culture Results in Patients with a Suspected or Confirmed Prosthetic Joint Infection: a Systematic Review.

J Clin Microbiol. 2017 Sep;55(9):2765-2774.                    

Wouthuyzen-Bakker M1, Benito N2, Soriano A3.

Author information

1 Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands m.wouthuyzen-bakker@umcg.nl.

2 Infectious Diseases Unit, Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau, Institut d’Investigació Biomèdica Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.

3 Service of Infectious Diseases, Hospital Clínic, University of Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.

Abstract

Obtaining reliable cultures during revision arthroplasty is important to adequately diagnose and treat a prosthetic joint infection (PJI). The influence of antimicrobial prophylaxis on culture results remains unclear. Since withholding prophylaxis increases the risk for surgical site infections, clarification on this topic is critical. A systematic review was performed with the following research question: in patients who undergo revision surgery of a prosthetic joint, does preoperative antimicrobial prophylaxis affect the culture yield of intraoperative samples in comparison with nonpreoperative antimicrobial prophylaxis? Seven articles were included in the final analysis. In most studies, standard diagnostic culture techniques were used. In patients with a PJI, pooled analysis showed a culture yield of 88% (145/165) in the prophylaxis group versus 95% (344/362) in the nonprophylaxis group (P = 0.004). Subanalysis of patients with chronic PJIs showed positive cultures in 88% (78/89) versus 91% (52/57), respectively (P = 0.59). In patients with a suspected chronic infection, a maximum difference of 4% in culture yield between the prophylaxis and nonprophylaxis groups was observed. With the use of standard culture techniques, antimicrobial prophylaxis seems to affect cultures in a minority of patients. Along with the known risk of surgical site infections due to inadequate timing of antimicrobial prophylaxis, we discourage the postponement of prophylaxis until tissue samples are obtained in revision surgery. Future studies are necessary to conclude whether the small percentage of false-negative cultures after prophylaxis can be further reduced with the use of more-sensitive culture techniques, like sonication.

PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5648712/pdf/zjm2765.pdf

 

July 31, 2018 at 6:50 pm

Analysis of 10 years of surveillance of infections associated with hip and knee prostheses

International Journal of Infectious Diseases August 2018 V.73 Supplement P.21

Corral, L. Guerriero, L. Fernandez, D. Arcidiacono, R. Giordano Lerena, N. Peralta

Background

Surgical site infections are the third reported cause of healthcare-associated infections (HAIs), representing 14% to 16% of them.

Prosthetic joint infection (PJI) are one of the most frequent complications that lead to an increase in morbidity and mortality.

In the first world countries, surveillance systems report an approximate infection rate for total hip arthroplasties (THAs) and total knee arthroplasties (TKAs), from 0.5 to 1% and 0,5 to 2% respectively.

Due to the lack of knowledge of local epidemiology, we propose to describe the rates associated with these procedures, the most frequent microbiological isolations and their resistance patterns.

Methods & Materials

A retrospective study, from 2006 to 2016, of the PJI episodes of THAs and TKAs was carried out through the review of the events reported by all the institutions in Argentina that voluntarily joined the National Surveillance System (VIHDA) for HAI and selected such procedures.

Results

They were surveyed 11114 THAs and 4262 TKAs, presenting 410 and 157 PJIs respectively, which constituted a global rate for the period described of 3.68% for THAs and 3.69% for TKAs.

The mean age for THAs and AR were 65.5 and 71 years, respectively.

Female sex predominated for both procedures with 62.7% (hips) and 61.8% (knees).

The main etiologies for THAs infections were Staphylococcus aureus (n = 153, 43% MRSA), Pseudomonas aeruginosa (n = 69, 22% resistant to ciprofloxacin), Escherichia coli (n = 62, 42% resistant to ciprofloxacin), and coagulase-negative Staphylococcus (n = 52, 54% methicillin-resistant). In TKAs infections, the most commonly found microorganisms were: Staphylococcus aureus (n = 41, 20% MRSA), coagulase-negative Staphylococcus (n = 38, 32% methicillin-resistant), Enterococcus sp. (n = 9; 0% resistant to vancomycin) and Pseudomonas aeruginosa (n = 8; 50% resistant to ciprofloxacin). 32% of THAs infections and 18% of TKAs infections were polymicrobial.

Conclusion

The infection rates in both procedures were similar, being relatively low.

The mean age was lower for THAs and the female sex predominated in both surgeries.

In TKAs, gram-positive cocci (77%) predominated over gram-negative bacilli (23%).

The THAs perceives the similar percentages of Gram-positive cocci isolates (48%) and Gram-negative bacilli (52%), with 2/3 of the Enterobacteriae.

A high rate of isolations of resistant microorganisms was observed.

PDF

https://www.ijidonline.com/article/S1201-9712(18)33556-2/pdf

July 29, 2018 at 11:57 am

JULY 2018 – Risk Factors for Surgical Site Infection After Cholecystectomy

Background.

There are limited data on risk factors for surgical site infection (SSI) after open or laparoscopic cholecystectomy.

Methods.

A retrospective cohort of commercially insured persons aged 18–64 years was assembled using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure or Current Procedural Terminology, 4th edition codes for cholecystectomy from December 31, 2004 to December 31, 2010. Complex procedures and patients (eg, cancer, end-stage renal disease) and procedures with pre-existing infection were excluded. Surgical site infections within 90 days after cholecystectomy were identified by ICD-9-CM diagnosis codes. A Cox proportional hazards model was used to identify independent risk factors for SSI.

Results.

Surgical site infections were identified after 472 of 66566 (0.71%) cholecystectomies; incidence was higher after open (n = 51, 4.93%) versus laparoscopic procedures (n = 421, 0.64%; P < .001). Independent risk factors for SSI included male gender, preoperative chronic anemia, diabetes, drug abuse, malnutrition/weight loss, obesity, smoking-related diseases, previous Staphylococcus aureus infection, laparoscopic approach with acute cholecystitis/obstruction (hazards ratio [HR], 1.58; 95% confidence interval [CI], 1.27–1.96), open approach with (HR, 4.29; 95% CI, 2.45–7.52) or without acute cholecystitis/obstruction (HR, 4.04; 95% CI, 1.96–8.34), conversion to open approach with (HR, 4.71; 95% CI, 2.74–8.10) or without acute cholecystitis/obstruction (HR, 7.11; 95% CI, 3.87–13.08), bile duct exploration, postoperative chronic anemia, and postoperative pneumonia or urinary tract infection.

Conclusions.

Acute cholecystitis or obstruction was associated with significantly increased risk of SSI with laparoscopic but not open cholecystectomy. The risk of SSI was similar for planned open and converted procedures. These findings suggest that stratification by operative factors is important when comparing SSI rates between facilities.

FULL TEXT

https://academic.oup.com/ofid/article/4/2/ofx036/3044173

PDF (CLIC en PDF)

July 15, 2018 at 4:00 pm

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