The diagnosis of peri-prosthetic bone and joint infections relies on converging information from clinical, laboratory and imaging assessments. Clinical findings alone may suffice: a sinus tract is a ...major criterion that establishes the diagnosis of infection. Identifying the causative organism is crucial and requires the early collection of high-quality samples from sites in contact with the prosthetic material. The bacteriological samples may be obtained by aspiration or open surgery. Imaging techniques have undergone remarkable improvements over the last two decades. Ultrasonography can be performed early and can be used to guide a needle biopsy if appropriate. Computed tomography or magnetic resonance imaging shows the extent of bone and/or soft-tissue involvement, provided effective artefact-suppression techniques are applied. Nuclear medicine methods have an undefined place in the diagnostic strategy and their possible role must be evaluated during a multidisciplinary discussion. The array of new laboratory methods introduced in recent years includes microbiological culture techniques, molecular biology tests, antigen and antibody assays and tests for immune markers in blood and/or joint fluid. When the first-line investigations fail to provide a definitive diagnosis, a multidisciplinary discussion at a referral centre for complex osteo-articular infections makes a major contribution to defining the subsequent diagnostic strategy. This lecture focusses on the following six questions: does the clinical assessment still have diagnostic relevance? What is the diagnostic contribution of imaging studies? Must the infection be documented pre-operatively and if so, how? Which microbiological techniques should be used? Which non-microbiological investigations help to diagnosis peri-prosthetic bone and joint infections? What role do referral centres for complex bone and joint infections play in the diagnostic strategy?
Management of septic bursitis Lormeau, Christian; Cormier, Grégoire; Sigaux, Johanna ...
Joint, bone, spine : revue du rhumatisme,
October 2019, 2019-Oct, 2019-10-00, 20191001, Letnik:
86, Številka:
5
Journal Article
Recenzirano
Superficial septic bursitis is common, although accurate incidence data are lacking. The olecranon and prepatellar bursae are the sites most often affected. Whereas the clinical diagnosis of ...superficial bursitis is readily made, differentiating aseptic from septic bursitis usually requires examination of aspirated bursal fluid. Ultrasonography is useful both for assisting in the diagnosis and for guiding the aspiration. Staphylococcus aureus is responsible for 80% of cases of superficial septic bursitis. Deep septic bursitis is uncommon and often diagnosed late. The management of septic bursitis varies considerably across centers, notably regarding the use of surgery. Controlled trials are needed to establish standardized recommendations regarding antibiotic treatment protocols and the indications of surgery.
Paradoxical reaction (PR) and immune reconstitution inflammatory syndrome (IRIS) are common complications of tuberculosis treatment. Corticosteroids are first-line treatment for severe PR or IRIS, ...particularly neurological. We report four cases of severe PR or IRIS during tuberculosis treatment who required TNF-α antagonists, and identified 20 additional cases through literature review. They were 14 women and 10 men, with a median age of 36 years (interquartile range, 28–52). Twelve were immunocompromised before tuberculosis: untreated HIV infection (
n
=6), or immunosuppressive treatment (TNF-α antagonists,
n
=5; tacrolimus,
n
=1). Tuberculosis was mostly neuromeningeal (
n
=15), pulmonary (
n
=10), lymph node (
n
=6), and miliary (
n
=6), multi-susceptible in 23 cases. PR or IRIS started after a median time of 6 weeks (IQR, 4–9) following anti-tuberculosis treatment start, and consisted primarily of tuberculomas (
n
=11), cerebral vasculitis (
n
=8), and lymphadenitis (
n
=6). First-line treatment of PR or IRIS was high-dose corticosteroids in 23 cases. TNF-α antagonists were used as salvage treatment in all cases, with infliximab (
n
=17), thalidomide (
n
=6), and adalimumab (
n
=3). All patients improved, but 6 had neurological sequelae, and 4 had TNF-α antagonist-related severe adverse events. TNF-α antagonists are safe and effective as salvage or corticosteroid-sparing therapeutic for severe PR or IRIS during tuberculosis treatment.
Postoperative infection is a major complication of spinal surgery with implants. We aimed to identify risk factors for, and characteristics of, postoperative spinal infections in children.
We ...performed a retrospective observational study of all children who underwent posterior spinal fusion with instrumentation in 2 referral hospitals in 2008-2013. Spinal infections were defined as local and/or general signs of infection that required surgical treatment in the early postoperative phase (ie, within 30 days). Data were collected on a standardized questionnaire from medical charts.
Of the 450 children who underwent spinal surgery, 26 (5.8%) were diagnosed with early postoperative spinal implant infection, with a median age of 14 years (interquartile range, 13-17) and a median delay of 13 days postsurgery (interquartile range, 7-18). Postoperative infection was more common in children with neurologic scoliosis as compared with idiopathic scoliosis (12.2% 15/123 versus 2.4% 5/211; P < 0.01). Neurologic scoliosis was an independent predictor of spinal implant infections (hazard ratio, 3.87 1.72-8.69; P < 0.001). Main pathogens were Staphylococcus aureus (n = 14) and Enterobacteriaceae (n = 8). All children underwent early surgery (wound exploration, debridement and lavage) and antibiotics for a median duration of 19 weeks interquartile range, 12-26. Two children (7.7%) required a second surgery. Spinal implants could be retained in all, and no relapse occurred with a follow-up of ≥24 months after antibiotic discontinuation.
Postoperative spinal implant infection is not rare in pediatric patients, especially with neurologic scoliosis. Most children may be cured with implant retention if managed with early surgery followed by a 3-month course of appropriate antibacterial agents.
•The treatment of prosthetic joint infections (PJIs) due to Streptococcus agalactiae is associated with a high risk of relapse.•The conservative approach with debridement and implant retention has a ...poor prognosis.•Debridement, antibiotics and implant retention (DAIR) with polyethylene exchange is probably associated with a higher chance of success.•The one-stage exchange strategy in selected patients has an excellent cure rate.•No antimicrobial treatment seems to be superior for PJIs with streptococcal species.
The optimal treatment of streptococcal prosthetic joint infections (PJIs) is unclear.
A cohort of streptococcal PJIs was reviewed retrospectively in seven reference centers for the management of complex bone and joint infections, covering the period January 1, 2010 to December 31, 2012.
Seventy patients with monomicrobial infections were included: 47 had infections of total hip arthroplasty and 23 had infections of total knee arthroplasty. The median age was 77 years (interquartile range (IQR) 69–83 years), the median Charlson comorbidity score was 4 (IQR 3–6), and 15.6% (n=11) had diabetes. The most commonly identified streptococcal species were Streptococcus agalactiae and Streptococcus dysgalactiae (38.6% (n=27) and 17.1% (n=12), respectively). Debridement, antibiotics and implant retention (DAIR) was performed after a median time of 7 days (IQR 3–8 days), with polyethylene exchange (PE) in 21% of cases. After a minimum follow-up of 2 years, 27% of patients had relapsed, corresponding to 51.4% of DAIR treatment cases and 0% of one-stage (n=15) or two-stage (n=17) exchange strategy cases. Rifampicin or levofloxacin in combination therapy was not associated with a better outcome (adjusted p= 0.99). S. agalactiae species and DAIR treatment were associated with a higher risk of failure. On multivariate analysis, only DAIR treatment and S. agalactiae were independent factors of relapse. Compared to DAIR without PE, DAIR with PE was only associated with a trend towards a benefit (odds ratio 0.33, 95% confidence interval 0.06–1.96; adjusted p= 0.44).
Streptococcal PJIs managed with DAIR have a poor prognosis and S. agalactiae seems to be an independent factor of treatment failure.
•Septic arthritis of the facet joints (SAFJ) is a severe infection, associated with infective endocarditis and neurological impairment.•Staphylococcus aureus and Streptococcus spp are the most ...frequent pathogens found in SAFJ.•One-year mortality was estimated to be 9.2% in our study and reached respectively 18.5% and 23% in years two and three.
Septic arthritis of the Facet Joints (SAFJ) is a rare condition. Little data has been published on the subject. We aimed to describe the clinical, biological and imagery presentations, as well as the course of this rare infection.
We included patients hospitalized between January 1st, 2016 and December 31th, 2019, in the Departments of Infectious Diseases or Rheumatology in 5 French centres in the CRIOGO network. We defined septic arthritis according to Newman's criteria and facet joint arthritis using imagery.
Sixty-five patients were included, predominantly males (64.6%), with a mean age of 68.1 years. The mean time to diagnosis was 25.0 days. The principal symptoms at diagnosis were acute back pain (95.2%) and fever (76.9%). Neurological symptoms were present for 60.7% of the patients, including 16.4% motor deficit or cauda equina syndrome. SAFJ was located on the lumbosacral spine (73.4%) and was rarely multifocal (4.7%). Bacteriological identification was performed by blood cultures in 84.4% of the cases, and the pathogen was mainly Staphylococcus aureus (49.2%). Infective endocarditis was present for 26.9% of patients assessed by echocardiography. On MRI, soft tissue abscess or inflammation, epiduritis and epidural abscess were present in 87.1%, 66.7% and 33.9% of cases, and the pathogen was significantly more frequently Staphylococcus aureus. Mortality reached 9.2%, 18.5% and 23% at one, two, and three years respectively.
SAFJ is a rare but severe disease. Microbiological diagnosis is primarily made on blood cultures, and S. Aureus was the main pathogen. Our results highlight the fact that SAFJ is associated with high morbidity and mortality, and with infective endocarditis.
Abstract
Background
Prosthetic joints are at risk of becoming infected during an episode of bacteremia, especially during Staphylocococcus aureus bacteremia. However, it is unclear how often ...asymptomatic periprosthetic joint infection (PJI) occurs, and whether additional diagnostics should be considered.
Methods
In this multicenter study, we retrospectively analyzed a cohort of patients with a late acute (hematogenous) PJI between 2005–2015 who had concomitant prosthetic joints in situ. Patients without at least 1 year of follow-up were excluded.
Results
We included 91 patients with a hematogenous PJI and 108 concomitant prosthetic joints. The incident PJI was most frequently caused by Staphylococcus aureus (43%), followed by streptococci (26%) and Gram-negative rods (18%). Of 108 concomitant prosthetic joints, 13 were symptomatic, of which 10 were subsequently diagnosed as a second PJI. Of the 95 asymptomatic prosthetic joints, 1 PJI developed during the follow-up period and was classified as a “missed” PJI at the time of bacteremia with S. aureus (1.1%). Infected prosthetic joints were younger than the noninfected ones in 67% of cases, and prosthetic knees were affected more often than prosthetic hips (78%).
Conclusions
During an episode of hematogenous PJI, concomitant asymptomatic prosthetic joints have a very low risk of being infected, and additional diagnostic work-up for these joints is not necessary.
We evaluated a cohort of patients with hematogenous periprosthetic joint infection and concomitant asymptomatic prosthetic joints. We demonstrate that if a prosthetic joint is asymptomatic, the chance of infection is very low. These joints do not require additional diagnostic work-up.
•Late acute prosthetic joint infection (PJI) treated with surgical debridement and implant retention have a high failure rate.•The exchange of mobile components during surgical debridement is the ...most potent predictor for treatment success.•There are several preoperative patient related variables that increase the risk for failure.•Treatment strategies for late acute PJIs should be individualized and optimized according to the preoperative risk for failing.
Debridement, antibiotics and implant retention (DAIR) is the recommended treatment for all acute prosthetic joint infections (PJI), but its efficacy in patients with late acute (LA) PJI is not well described.
Patients diagnosed with LA PJI between 2005 and 2015 were retrospectively evaluated. LA PJI was defined as the development of acute symptoms (≤ 3 weeks) occurring ≥ 3 months after arthroplasty. Failure was defined as: (i) the need for implant removal, (ii) infection related death, (iii) the need for suppressive antibiotic therapy and/or (iv) relapse or reinfection during follow-up.
340 patients from 27 centers were included. The overall failure rate was 45.0% (153/340). Failure was dominated by Staphylococcus aureus PJI (54.7%, 76/139). Significant independent preoperative risk factors for failure according to the multivariate analysis were: fracture as indication for the prosthesis (odds ratio (OR) 5.4), rheumatoid arthritis (OR 5.1), age above 80 years (OR 2.6), male gender (OR 2.0) and C-reactive protein > 150 mg/L (OR 2.0). Exchanging the mobile components during DAIR was the strongest predictor for treatment success (OR 0.35).
LA PJIs have a high failure rate. Treatment strategies should be individualized according to patients’ age, comorbidity, clinical presentation and microorganism causing the infection.
Fluoroquinolones efficacy depend on both the drug exposure and the level of drug resistance of the bacteria responsible for the infection. Specifically for the Staphylococcus species, which is the ...microorganism mainly involved in osteoarticular infections (OAI), in-vitro data reported that an AUC/MIC ratio above 115 h maximizes drug efficacy. However, data on OAI patients are lacking and a simple approach to access AUCs is still a clinical issue. We conducted a prospective, single-center study in 30 OAI patients hospitalized in the Rennes University Hospital to model ofloxacin pharmacokinetics and to define a limited sampling strategy (LSS) suitable for ofloxacin and levofloxacin treatments. Modeling was conducted with the Monolix software. The final model was externally validated using levofloxacin data. Monte-Carlo simulations were used to evaluate the probability of target attainment (PTA) of different dosing regimens. Two hundred and ninety-seven (297) ofloxacin concentrations were available for the pharmacokinetic modeling. Ofloxacin pharmacokinetics was best described using a bicompartmental model with a first order elimination, and a transit compartment model absorption. CKD-EPI and sex explained half of ofloxacin pharmacokinetic variability. For LSS, the 0, 1 h and 3 h sampling scheme resulted in the best approach both for BID and TID dosages (R2 adjusted = 91.1% and 95.0%, outliers = 4.8% and 5.0%, respectively). PTA allows choosing the best drug and dosage according to various hypotheses. A simple 3-sample protocol (pre-dose, 1 h after intake and 3 h after intake) to estimate ofloxacin and levofloxacin AUC allows optimal drug dosage for the treatment of osteoarticular infections.
Objectives
To minimize confounding factors, we aimed to describe the changes in weight and body mass index (BMI) following the single substitution of tenofovir disoproxil fumarate (TDF) by tenofovir ...alafenamide (TAF) in people living with HIV (PLWH).
Methods
We designed a retrospective study in a large French cohort. We included all HIV‐suppressed adults under TDF + emtricitabine + rilpivirine or elvitegravir/cobistat, who experienced a first switch from TDF to TAF, while other antiretrovirals remained unchanged (Switch group). We compared this population to a propensity score‐matched Control group (1:1) who stayed on the same TDF‐based regimen. Changes were evaluated after 6 (M6) and 12 months (M12).
Results
Some 1260 and 468 PLWH were evaluable per group at M6 and M12, respectively. In the Switch group, there was a mean (95% confidence interval 95% CI) weight gain of +1014 g (+826 to +1201) at M6 (p < 0.0001) and +1365 g (+910 to +1820) at M12 (p < 0.0001), as compared with baseline. Meanwhile, there was no significant weight gain at M6 (+139 g −50 to +328) and M12 (−32 g −413 to +350) in the matched Control group. Similarly, mean BMI increased significantly in the Switch group at M6 (+0.35, 95% CI: +0.29 to +0.41, p < 0.0001) and M12 (+0.49, 95% CI: +0.32 to +0.65, p < 0.0001), while it was stable at M6 (+0.05, 95% CI: −0.01 to +0.12, p = 0.11) and M12 (+0.01, 95% CI: −0.12 to +0.14, p = 0.89) in the No Switch group.
Conclusions
Although modest, there is a significant weight gain following the substitution of TDF by TAF. This should be anticipated in certain at‐risk populations.
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