Journal of Bone and Joint Infection最新文献

Native vertebral osteomyelitis (NVO) is a potentially fatal infection which has seen a gradual increase in its incidence over the past decades. The infection is insidious, presenting with symptoms of back pain. Fever is present in about 60 % of patients. Prompt diagnosis of NVO is important to prevent the development of complications. Numerous laboratory and imaging tools can be deployed to accurately establish the diagnosis. Imaging techniques such as magnetic resonance, nuclear imaging, and computed tomography are essential in diagnosing NVO but can also be useful in image-guided biopsies. Laboratory tools include routine blood tests, inflammatory markers, and routine culture techniques of aspirated specimens. Recent advances in molecular techniques can assist in identifying offending pathogen(s). In this review, we detail the arsenal of techniques that can be utilized to reach a diagnosis of NVO.

Purpose: Debridement, antibiotics, and implant retention (DAIR) is an established treatment modality in periprosthetic joint infections (PJIs), but success rates vary. This study compared the success of DAIR for PJIs after a total hip arthroplasty (THA), with or without local antibiotic delivery with CaSO ${}_4$ as the carrier material. Methods: A retrospective review of DAIR for PJIs after THA performed between 2010 and 2018, including 41 patients is conducted. A total of 27 patients were treated by DAIR with local antibiotics with CaSO ${}_4$ as the carrier material, and 14 patients were treated by a standard DAIR. The endpoints were treatment failure, defined as the need for a reoperation, either a second DAIR or a prosthesis removal or exchange due to persistent or recurrent infection, the initiation of a long-term suppressive antibiotic treatment, or death related to infection. Results: Considering any reoperation as an outcome, 11 of 14 cases treated without AB-CaSO ${}_4$ (79 %) and 4 of the 27 cases treated with AB-CaSO ${}_4$ failed (15 %). Considering revision as an outcome, 9 out of 14 cases treated without AB-CaSO ${}_4$ (64 %) and 4 of the 27 cases treated with AB-CaSO ${}_4$ (15 %) failed. A Kaplan-Meier survival analysis showed that local antibiotic delivery with CaSO ${}_4$ as the carrier material led to a significantly longer infection-free survival, considering any surgical revision ( $p<0.0001$ ; hazard ratio 8.9 (95 % CI 2.8-28.2)) or revision with component exchange ( $p=0.0015$ ; hazard ratio 5.6 (95 % CI 1.7-18.2)) as the endpoint. Conclusion: The addition of local antibiotics with CaSO ${}_4$ as the carrier material to DAIR for PJIs after THA significantly increases success rates, such as infection-free survival, any reoperation, and revision with component exchange in particular.

Background: A low-grade periprosthetic joint infection (PJI) may present without specific symptoms, and its diagnosis remains a challenge. Three-phase bone scintigraphy (TPBS) and white blood cell (WBC) scintigraphy are incorporated into recently introduced diagnostic criteria for PJI, but their exact value in diagnosing low-grade PJI in patients with nonspecific symptoms remains unclear. Methods: In this retrospective study, we evaluated patients with a prosthetic joint of the hip or knee who underwent TPBS and/or WBC scintigraphy between 2009 and 2016 because of nonspecific symptoms. We reviewed and calculated diagnostic accuracy of the TPBS and/or WBC scintigraphy to diagnose or exclude PJI. PJI was defined based on multiple cultures obtained during revision surgery. In patients who did not undergo revision surgery, PJI was ruled out by clinical follow-up of at least 2 years absent of clinical signs of infection based on MSIS 2011 criteria. Results: A total of 373 patients were evaluated, including 340 TPBSs and 142 WBC scintigraphies. Thirteen patients (3.5 %) were diagnosed with a PJI. TPBS sensitivity, specificity, and positive and negative predictive values (PPV, NPV) were 71 %, 65 %, 8 % and 98 %, respectively. Thirty-five percent of TPBS showed increased uptake. Stratification for time intervals between the index arthroplasty and the onset of symptoms did not alter its diagnostic accuracy. WBC scintigraphy sensitivity, specificity, PPV and NPV were 30 %, 90 %, 25 % and 94 %, respectively. Conclusion: Nuclear imaging does not have clear added value in patients with low a priori chance of periprosthetic joint infection.

The aim of this study was to review the available literature concerning Madura foot ("mycetoma") caused by Madurella mycetomatis in immunocompromised patients. With a systematic literature search, we identified only three papers, describing a total of three immunocompromised patients. Hence, the clinical presentation and prognosis of the disease in this patient population have not yet been well described. In addition, we present a case from our institution, illustrating the complexity of the treatment of this rare disease. Although very rare in non-endemic countries, we emphasize that mycetoma should be included in the differential diagnoses of (immunocompromised) patients who have been residing in a geographical area where the disease is endemic and presenting with soft tissue inflammation of one of the extremities.

Diabetic foot infection is a frequent complication in long-standing diabetes mellitus. For antimicrobial therapy of this infection, both the optimal duration and the route of administration are often based more on expert opinion than on published evidence. We reviewed the scientific literature, specifically seeking prospective trials, and aimed at addressing two clinical issues: (1) shortening the currently recommended antibiotic duration and (2) using oral (rather than parenteral) therapy, especially after the patient has undergone debridement and revascularization. We also reviewed some older key articles that are critical to our understanding of the treatment of these infections, particularly with respect to diabetic foot osteomyelitis. Our conclusion is that the maximum duration of antibiotic therapy for osteomyelitis should be no more than to 4-6 weeks and might even be shorter in selected cases. In the future, in addition to conducting randomized trials and propagating national and international guidance, we should also explore innovative strategies, such as intraosseous antibiotic agents and bacteriophages.

Background: Diagnosing periprosthetic joint infection (PJI) is challenging and usually requires the evaluation of several biomarkers. Our main aim was to evaluate the usefulness of D-dimer levels as well as the platelet count (PC) to mean platelet volume (MPV) ratio serum as biomarkers to rule out chronic knee and hip infection. Methods: The study enrolled a prospective cohort of 93 patients undergoing hip or knee revision. D-dimer values, PC to MPV ratio, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were preoperatively determined and evaluated as a predictor of PJI. The definitive diagnosis of PJI was established according to the 2018 International Consensus Meeting criteria. Results: A total of 24 (25.8 %) cases were postoperatively diagnosed with PJI. The median D-dimer value was significantly higher ( $p$   $<$  0.001) for patients with PJI (1950 ng mL ${}^{-1}$ ) than for patients with aseptic failure (700 ng mL ${}^{-1}$ ). The area under the receiver operating characteristic curves for D-dimer, CRP and ESR was 0.820, 0.793 and 0.791 respectively. D-dimer  $\ge$  950 ng mL ${}^{-1}$ (91 % sensitivity, 64 % specificity), CRP  $\ge$  1.95 mg dL ${}^{-1}$ (61 % sensitivity, 90 % specificity) and ESR  $>$  20 (74 % sensitivity, 82 % specificity) were identified as the values with the best balance between sensitivity and specificity. The mean PC to MPV ratio was 37.0 for PJI patients and 29.8 for patients in the aseptic revision cohort ( $p=0$ .067). Conclusions: Serum D-dimer levels appear very unlikely to remain normal in the presence of chronic PJI. The 91 % sensitivity when considering 950 ng mL ${}^{-1}$ as the threshold highlights D-dimer as the most accurate initial test to rule out chronic PJI. Conversely, the PC to MPV ratio may be of limited value for accurately diagnosing PJI.

Forty years ago I made a radical professional choice: to dedicate a few years of practice to the African continent. Not surprisingly, a few years became many. This paper is dedicated to the children who are battling osteoarticular infections and to those who will be struggling with them in future.

Recent data suggest that oral therapy can be effective for bone infections. We aim to assess the efficacy of an early switch to oral therapy ( $<2$  weeks) compared to a non-early switch in bacterial native vertebral osteomyelitis. We conducted a cohort study at Mayo Clinic, Rochester (MN), between 2019-2021 combined with a systematic review, which queried multiple databases. Data were analyzed using a random-effects model. The cohort study included 139 patients: two received an early switch. Of 3708 citations, 13 studies were included in the final analysis. Meta-analysis demonstrated no difference in treatment failure (odds ratio  $=$  1.073, 95 % confidence interval 0.370-3.116), but many studies presented high risk of bias. Current evidence is insufficient to conclude the proportion of patients with failure or relapse is different in the two groups. High-quality studies are warranted before early switch can be routinely recommended.

Purpose: The purpose of this study was the clinical and therapeutic assessment of lower-limb osteosynthesis-associated infection (OAI) by multidrug-resistant (MDR) and extensively drug-resistant (XDR) Gram-negative bacteria (GNB), which have been poorly studied to date. Methods: A prospective multicentre observational study was conducted on behalf of ESGIAI (the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group on Implant-Associated Infections). Factors associated with remission of the infection were evaluated by multivariate and Cox regression analysis for a 24-month follow-up period. Results: Patients ( $n=57$ ) had a history of trauma (87.7 %), tumour resection (7 %) and other bone lesions (5.3 %). Pathogens included Escherichia coli ( $n=16$ ), Pseudomonas aeruginosa ( $n=14$ ; XDR 50 %), Klebsiella spp. ( $n=7$ ), Enterobacter spp. ( $n=9$ ), Acinetobacter spp. ( $n=5$ ), Proteus mirabilis ( $n=3$ ), Serratia marcescens ( $n=2$ ) and Stenotrophomonas maltophilia ( $n=1$ ). The prevalence of ESBL (extended-spectrum $\beta$ -lactamase), fluoroquinolone and carbapenem resistance were 71.9 %, 59.6 % and 17.5 % respectively. Most patients ( $n=37$ ; 64.9 %) were treated with a combination including carbapenems ( $n=32$ ) and colistin ( $n=11$ ) for a mean of 63.3 d. Implant retention with debridement occurred in early OAI (66.7 %), whereas the infected device was removed in late OAI (70.4 %) ( $p=0.008$ ). OAI remission was achieved in 29 cases (50.9 %). The type of surgery, antimicrobial resistance and duration of treatment did not significantly influence the outcome. Independent predictors of the failure to eradicate OAI were age $>60$  years (hazard ratio, HR, of 3.875; 95 % confidence interval, CI95 %, of 1.540-9.752; $p=0.004$ ) and multiple surgeries for OAI (HR of 2.822; CI95 % of 1.144-6.963; $p=0.024$ ). Conclusions: Only half of the MDR/XDR GNB OAI cases treated by antimicrobials and surgery had a successful outcome. Advanced age and multiple surgeries hamper

The number of biomedical research articles increases by over 2.5 million publications each year, making it difficult to stay up to date. In this study, we introduce a standardized search and evaluation tool to combat this issue. Employing crowdsourcing, a large database of publications is gathered. Using a standardized data entry format, coined the "scientific publication score" (SPS), specific publication results can be easily aggregated, thereby allowing fast and accurate comparisons for clinical questions. The SPS combines two quality dimensions. The first captures the quality of evidence of the study using the evidence criteria defined by the Centre for Evidence-Based Medicine, Oxford, UK. The second is more fine-grained and considers the magnitude of statistical analyses on individual and specific results. From 2014 to 2019, experts of the European Bone and Joint Infection Society (EBJIS) were asked to enter data of relevant publications about prosthetic joint infection. Data and evidence levels of specific results were averaged, summarized and ranked. A total of 366 publications were divided into two groups: (I) risk factors (e.g., host-related factors, pre- and postoperative issues) with 243 publications and (II) diagnostic methods (e.g., laboratory tests, imaging methods) with 123 publications. After ranking, the highest score for risk factors of prosthetic joint infection were calculated by the SPS for anemia (mean $3.50\pm$  SD 0.91), malignancy (mean $3.17\pm$  SD 0.29) and previous alloarthroplasty (mean $3.00\pm$  SD 0.35). A comparison of the full SPS ranking with the ranking determined at the 2018 International Consensus Meeting (ICM) on Musculoskeletal Infection resulted in a Spearman rank correlation coefficient of 0.48 and a $p$  value of 0.0382. The diagnostic methods ranked highest by the SPS were aspirate leucocyte count (mean $3.15\pm$  SD 1.21), interleukin 6 (mean $3.14\pm$  SD 1.07) and aspirate (neutrophils over 80 %) (mean $3.12\pm$  SD 0.63). The comparison to the ICM ranking yielded a Spearman rank correlation coefficient of 0.91 and a $p$  value of 0.0015. Our pilot study evaluated a new tool for the quality assessment of specific results based on the quality of the source publication. The SPS is suitable for a ranking of specific results by evidence and data quality criteria important for systematic reviews.