Academic literature on the topic 'Osteoarticualr infection'

Infection is a dire complication afflicting every field of orthopaedics and traumatology. If specific clinical, laboratory and imaging parameters are present, infection is often assumed even in the absence of microbiological confirmation. However, apart from confirming infection, knowing the exact infecting pathogen(s) and their antimicrobial susceptibility patterns is paramount to help guide treatment. Every effort should therefore be undertaken with that goal in mind. Not all microbiological findings carry the same relevance, and knowing exactly how and where a sample was collected is key. Several different sampling techniques are available, and one must be aware of both advantages and limitations. Microbiological sampling alternatives in some of the most common clinical scenarios such as native and prosthetic joint infections, osteomyelitis and fracture-related infections, spinal and diabetic foot infections will be discussed. Orthopaedic surgeons should also be aware of basic laboratory sample processing techniques as they have a direct impact on the way specimens should be dealt with and transported to the laboratory. Only by knowing these basic principles will surgeons be able to participate in the multidisciplinary discussion and decision making around how to interpret microbiological findings in each specific patient. Cite this article: EFORT Open Rev 2021;6:390-398. DOI: 10.1302/2058-5241.6.210011

Introduction. Kytococcus schroeteri is an infrequently isolated Gram-positive coccus often encountered as a commensal bacterium. Only eighteen cases of human infection associated with this organism have been previously reported. Most of these cases involved patients with implanted prosthetic materials or patients with immunosuppressive conditions. It has been described in prosthetic valve endocarditis and in select patients with hematologic diseases but only one prior report as being involved in osteoarticular infections. Case Presentation. We describe a case of postsurgical osteoarticular hardware-related infection by K. schroeteri and discuss a possible association with implanted prosthetic material. Conclusion. Other clinical presentations of K. schroeteri, including reported infection syndromes, antimicrobial susceptibility profiles, and treatment outcomes, are also reviewed.

Aims We aimed to describe the epidemiological, biological, and bacteriological characteristics of osteoarticular infections (OAIs) caused by Kingella kingae. Methods The medical charts of all children presenting with OAIs to our institution over a 13-year period (January 2007 to December 2019) were reviewed. Among these patients, we extracted those which presented an OAI caused by K. kingae and their epidemiological data, biological results, and bacteriological aetiologies were assessed. Results K. kingae was the main reported microorganism in our paediatric population, being responsible for 48.7% of OAIs confirmed bacteriologically. K. kingae affects primarily children aged between six months and 48 months. The highest prevalence of OAI caused by K. kingae was between seven months and 24 months old. After the patients were 27 months old, its incidence decreased significantly. The incidence though of infection throughout the year showed no significant differences. Three-quarters of patients with an OAI caused by K. kingae were afebrile at hospital admission, 11% had elevated WBCs, and 61.2% had abnormal CRPs, whereas the ESR was increased in 75%, constituting the most significant predictor of an OAI. On MRI, we noted 53% of arthritis affecting mostly the knee and 31% of osteomyelitis located primarily in the foot. Conclusion K. kingae should be recognized currently as the primary pathogen causing OAI in children younger than 48 months old. Diagnosis of an OAI caused by K. kingae is not always obvious, since this infection may occur with a mild-to-moderate clinical and biological inflammatory response. Extensive use of nucleic acid amplification assays improved the detection of fastidious pathogens and has increased the observed incidence of OAI, especially in children aged between six months and 48 months. We propose the incorporation of polymerase chain reaction assays into modern diagnostic algorithms for OAIs to better identify the bacteriological aetiology of OAIs. Cite this article: Bone Joint J 2021;103-B(3):578–583.

Yokenella regensburgei belongs to the family Enterobacteriaceae and is an opportunistic agent rarely associated with infections in humans. We report a case of osteoarticular knee infection caused by Y. regensburgei in a patient under treatment for rheumatoid arthritis, using corticosteroids, with complication in primary total arthroplasty of the knee. Y. regensburgei was identified using the VITEK2 system. Antimicrobial susceptibility testing was performed using the disk-diffusion method, according to the guidelines from the Clinical and Laboratory Standards Institute. The patient presented favorable clinical evolution after the second debridement, with complete removal of the prosthesis and antibiotic therapy with sulfamethoxazole/trimethoprim. This is the first case of Y. regensburgei infection described d in Brazil. KEY WORDS: Yokenella regensburgei; osteoarticular; infection; sulfamethoxazole; trimethoprim; prosthesis.

Dalbavancin is a lipoglycopeptide approved for treatment of Gram-positive infections of skin and skin-associated structures (ABSSSI). Currently, off-label use at high dosages for osteoarticular infections deserves attention. This work aimed to study the long-term plasma pharmacokinetics of dalbavancin in outpatients with ABSSSI or osteoarticular infections, treated either with one or two 1500 mg doses of dalbavancin. A liquid chromatography-tandem mass spectrometry method was used to measure total dalbavancin concentrations in plasma samples. The results were analyzed through a non-compartmental analysis (NCA). Breakpoint minimum inhibitory concentration (MIC) was used to calculate AUC/MIC and T > MIC parameters, adjusted by 93% protein binding. A total of 14 patients were enrolled, 11 with osteoarticular infection and 3 with ABSSSI. Long-term pharmacokinetics showed median T > MIC (0.125 mg/L) of 11.9 and 13.7 weeks for single and dual dose, respectively. Similarly, median AUC0-2w/MIC ratios of 20,590 and 31,366 were observed for single and dual dose regimens, respectively. No adverse events were observed, and treatment success was achieved in 12/14 patients. Failure was associated with the worst clinical conditions, bone infections, and single dose. The results of this study show that dalbavancin exposure exceeds previously suggested pharmacodynamic targets. Optimization of these targets is needed for the osteoarticular setting.

Nowadays, Kingella kingae (K. kingae) is considered as the main bacterial cause of osteoarticular infections (OAI) in children aged less than 48 months. Next to classical acute hematogenous osteomyelitis and septic arthritis, invasive K. kingae infections can also give rise to atypical osteoarticular infections, such as cellulitis, pyomyositis, bursitis, or tendon sheath infections. Clinically, K. kingae OAI are usually characterized by a mild clinical presentation and by a modest biologic inflammatory response to infection. Most of the time, children with skeletal system infections due to K. kingae would not require invasive surgical procedures, except maybe for excluding pyogenic germs’ implication. In addition, K. kingae’s OAI respond well even to short antibiotics treatments, and, therefore, the management of these infections requires only short hospitalization, and most of the patients can then be treated safely as outpatients.

Osteoarticular infections are frequent in the clinical practice and have a high impact on patients and health systems. These infections may be associated with concomitant bacteremia and a characteristic feature is the presence of bacterial biofilm, which limits the efficacy of antimicrobial therapy. In recent years, the emergence of multidrug-resistant microorganisms has resulted in the need of new antimicrobial alternatives to improve patients’ outcomes. In this line, translational research plays a key role in providing therapeutic alternatives for the global management of osteoarticular infections. This thesis included clinical and experimental studies to deepen on the available knowledge of bacteremic osteoarticular infections (BOAs) and antimicrobial alternatives for these infections by Pseudomonas aeruginosa. The first part of the thesis included four observational studies on bacteremic osteoarticular infections, performed at Hospital Universitari de Bellvitge (1985-2014). We observed that the incidence of BOAs increased during the study period, at the expense of nosocomial and healthcare-related infections, vertebral osteomyelitis (VO) and those affecting devices. Cases by methicillin-resistant Staphylococcus aureus (MRSA), Streptococci, Enterococci and Gram-negative bacilli (GNB) also increased. We then analyzed the association between BOAs and infective endocarditis (70 cases, 11.5% of endocarditis, 15% of OAs); there was an association between BOAs of the axial skeleton (arthritis or VO) and the presence of infective endocarditis. VO was mainly caused by low-virulent microorganisms (viridans and bovis Streptococci, Enterococci and coagulase-negative Staphylococci), whereas arthritis of the axial skeleton was mainly caused by S. aureus. The third study compared the characteristics of bacteremic septic arthritis according to the site acquisition. Nosocomial and healthcare-related cases affected more frequently older patients and with comorbidities and caused by MRSA and P. aeruginosa. Infections affecting the axial skeleton were more frequent in community-acquired and healthcare-related cases, whereas prosthetic joint infection was more common in nosocomial cases. Finally, 30-day mortality of BOAs was 12.2%, which was higher in peripheral septic arthritis and cases by MRSA. Mortality was lower in patients with peripheral septic arthritis managed with surgical debridement. The second part of the thesis evaluated the role of therapeutic alternatives in OAs by P. aeruginosa. The first study was an observational study, which analysed the efficacy and therapeutic drug monitoring of continuous beta-lactam infusion in OAs by fluoroquinolone-resistant P. aeruginosa at Hospital Universitari de Bellvitge (2016-2018). 52 patients were included, 19 with fluoroquinolone-resistant strains (13; 68.4% MDR/XDR). Most patients had beta-lactam concentrations between 3-10xMIC and higher concentrations occurred in patients with renal impairment. There were no differences in failure rates between patients with fluoroquinolone-susceptible or resistant strains. The last two studies were experimental and used a dynamic in vitro biofilm model, the CDC Biofilm Reactor. The first evaluated the activity of ceftolozane-tazobactam, with/without colistin, against three MDR/XDR P. aeruginosa strains. Ceftolozane-tazobactam in monotherapy was ineffective and meropenem monotherapy was bactericidal against carbapenem-susceptible strains. Colistin was intitially effective, but regrowth occurred at the end of the experiments. Beta-lactam plus colistin combinations were more effective than monotherapies and prevented the emergence of colistin-resistant strains. Ceftolozane-tazobactam plus colistin was the most effective combination againts carbapenem-resistant strains, whereas meropenem plus colistin was for carbapenem-susceptible strains. The second study evaluated the pharmacokinetics/pharmacodynamics of continuous ceftazidime infusion, with/without colistin, against two susceptible strains (PAO1 and HUB8); growing clinically-achievable concentrations of ceftazidime (4-10-20-40 mg/L) were used. Higher ceftazidime concentrations (20-40) in monotherapy had higher anti-biofilm activity against PAO1, but not against HUB8. Ceftazidime resistance emerged with lower concentrations. Combinations of ceftazidime plus colistin increased the activity of monotherapies and prevented the emergence of colistin and ceftazidime resistance. With combinations against both strains, 40mg/L ceftazidime plus colistin had higher efficacy than 4mg/L ceftazidime plus colistin.
Los estudios clínicos y experimentales de esta tesis pretenden ampliar la información existente sobre las infecciones osteoarticulares bacteriémicas así como evaluar alternativas terapéuticas para estas infecciones por P. aeruginosa. La primera parte de la tesis aborda la problemática de las infecciones osteoarticulares bacteriémicas e incluye 4 estudios realizados en el Hospital Universitari de Bellvitge (1985-2014). La incidencia de infecciones osteoarticulares aumentó a lo largo de los años, con incremento de las infecciones nosocomiales y asociadas al ámbito sanitario, además de las infecciones asociadas a material ortopédico y la osteomielitis vertebral. Los casos por S. aureus meticilin-resistente (SARM), estreptococos, enterococos y bacilos gram-negativos aumentaron. La infección osteoarticular bacteriémica con afectación del esqueleto axial (artritis o espondilitis) se asoció independientemente a la presencia de endocarditis infecciosa. Los casos nosocomiales y asociados al ámbito sanitario se presentaron más frecuentemente en individuos mayores y con más comorbilidades y fueron causados por SARM y P. aeruginosa. La mortalidad fue del 12.2%, mayor en la artritis séptica periférica y en infecciones por SARM. La mortalidad fue menor en los pacientes con artritis séptica periférica tratados con desbridamiento quirúrgico. La segunda parte de la tesis pretende encontrar alternativas terapéuticas para la infección osteoarticular por P. aeruginosa. El primer estudio analiza infecciones osteoarticulares por P. aeruginosa tratados con beta-lactámicos en perfusión continua y monitorización plasmática de concentraciones. 52 pacientes incluidos, 19 con cepas resistentes a fluoroquinolonas (13;68.4% cepas MDR/XDR). La mayoría tenían concentraciones de 3-10xMIC, concentraciones superiores frecuntes en insuficiencia renal. No hubo diferencias en el fracaso entre aquellos con infecciones por cepas resistentes o sensible a fluoroquinolonas. Se realizaron dos estudios experimentales con un modelo in vitro dinámico de biofilm. El primero evalúa la actividad de ceftolozano-tazobactam, con/sin colistina, frente a P. aeruginosa multiresistente. Ceftolozano-tazobactam con colistina fue el tratamiento más eficaz ante la cepa resistente a meropenem, mientras que meropenem con colistina lo fue frente a cepas sensibles a carbapenems. El segundo analiza las características farmacocinéticas/farmacodinámicas de ceftazidima en infusión continua, con/sin colistina, frente P. aeruginosa sensible. Frente PAO1, se observó una actividad anti-biofilm ligeramente superior con concentraciones de ceftazidima de 20-40mg/L, además de mayor actividad anti-biofilm frente ambas cepas con combinaciones de colistina y ceftazidima a concentraciones de 40mg/L que con 4mg/L.

Objective: To synthesise the best available evidence for the diagnostic test accuracy of measurement of serum procalcitonin compared to serum C-reactive protein for suspected osteomyelitis and septic arthritis in hospitalised children and adolescents. Introduction: Measurement of serum C-reactive protein remains a routine investigation for the diagnosis of osteoarticular infection in children and adolescents. Measurement of serum procalcitonin has been shown to outperform C-reactive protein in adults with osteomyelitis and septic arthritis. Before procalcitonin can be considered as a potential replacement or additional test in children and adolescents, a systematic review and meta-analysis targeting this population is needed. Inclusion criteria: Original studies reporting on the diagnostic accuracy of procalcitonin and/or C-reactive protein in children and adolescents aged between one month and 18 years admitted to hospital with suspected osteoarticular infection were included, compared to at least one reference test. The reference test was defined as positive culture or polymerase chain reaction confirmation of a pathogen from blood and/or bone biopsy and/or joint fluid aspirate and/or at least two of the following: 1) purulent material from sterile site; 2) positive radiological findings consistent with osteoarticular infection; 3) symptoms and signs consistent with osteomyelitis and/or septic arthritis. Methods: JBI methodology for systematic reviews of diagnostic test accuracy was employed. Information was sourced from four databases; MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Web of Science and four grey literature sources; Mednar, OpenGrey, Google scholar and ProQuest Dissertations and Thesis. Only studies published in English were considered. The methodological quality of selected studies was formally evaluated and sensitivity and specificity data were extracted and 95% confidence intervals determined. Meta-analysis was performed to estimate summary points using a bivariate model and generate a hierarchial summary receiver operating characteristic curve (HSROC) with global measures of test accuracy performance including likelihood ratio and diagnostic odds ratio. A narrative summary was provided where meta-analysis was not feasible. Results: Eight out of 3086 studies were included in the final analysis. Four of these studies used a common CRP test threshold of 20mg/L for septic arthritis cases only. At this threshold the estimated pooled sensitivity of C-reactive protein was 0.86 (0.68-0.96) and the pooled specificity 0.9 (0.83-0.94). Using a HSROC model from six studies including all osteoarticular infections, the diagnostic odds ratio for C-reactive protein was estimated to be 39.4 (14.8-104.9) with a positive likelihood ratio 5.3 (2.3-11.9) and negative likelihood ratio 0.1 (0.07-0.2). There were insufficient studies from this review to statistically evaluate the diagnostic accuracy performance of procalcitonin using meta-analysis. Conclusion: We have synthesised the best available evidence to evaluate the diagnostic test accuracy of serum measurement of procalcitonin and C-reactive protein in children and adolescents with suspected osteomyelitis and septic arthritis. Clinicians should continue to measure serum C-reactive protein as the preferred inflammatory marker in this setting and await more evidence before incorporating procalcitonin routinely into their diagnostic test strategy for this specific setting.
Thesis (MClinSc) -- University of Adelaide, School of Public Health, 2020