Publications by authors named "Marjan Wouthuyzen-Bakker"

51 Publications

Risk Scores and Machine Learning to Identify Patients With Acute Periprosthetic Joints Infections That Will Likely Fail Classical Irrigation and Debridement.

Front Med (Lausanne) 2021 3;8:550095. Epub 2021 May 3.

Service of Infectious Diseases, Hospital Clínic, University of Barcelona, Barcelona, Spain.

The most preferred treatment for acute periprosthetic joint infection (PJI) is surgical debridement, antibiotics and retention of the implant (DAIR). The reported success of DAIR varies greatly and depends on a complex interplay of several host-related factors, duration of symptoms, the microorganism(s) causing the infection, its susceptibility to antibiotics and many others. Thus, there is a great clinical need to predict failure of the "classical" DAIR procedure so that this surgical option is offered to those most likely to succeed, but also to identify those patients who may benefit from more intensified antibiotic treatment regimens or new and innovative treatment strategies. In this review article, the current recommendations for DAIR will be discussed, a summary of independent risk factors for DAIR failure will be provided and the advantages and limitations of the clinical use of preoperative risk scores in early acute (post-surgical) and late acute (hematogenous) PJIs will be presented. In addition, the potential of implementing machine learning (artificial intelligence) in identifying patients who are at highest risk for failure of DAIR will be addressed. The ultimate goal is to maximally tailor and individualize treatment strategies and to avoid treatment generalization.
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http://dx.doi.org/10.3389/fmed.2021.550095DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8126631PMC
May 2021

If, when, and how to use rifampin in acute staphylococcal periprosthetic joint infections, a multicentre observational study.

Clin Infect Dis 2021 May 10. Epub 2021 May 10.

Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.

Background: Rifampin is generally advised in the treatment of acute staphylococcal periprosthetic joint infections (PJI). However, if, when, and how to use rifampinremains a matter of debate. We evaluated the outcome of patients treated with and without rifampin, and analyzed the influence of timing, dose and co-antibiotic.

Methods: Acute staphylococcal PJIs treated with surgical debridement between 1999 and 2017, and a minimal follow-up of 1 year were evaluated. Treatment failure was defined as the need for any further surgical procedure related to infection, PJI-related death or the need for suppressive antimicrobial treatment.

Results: A total of 669 patients were analyzed. Treatment failure was 32.2% (131/407) in patients treated with rifampin and 54.2% (142/262) in whom rifampin was withheld (P < 0.001). The most prominent effect of rifampin was observed in knees (treatment failure 28.6% versus 63.9%, respectively, P < 0.001). The use of rifampin was an independent predictor of treatment success in the multi-variate analysis (OR 0.30, 95% CI 0.20 - 0.45). In the rifampin group, the use of a co-antibiotic other than a fluoroquinolone or clindamycin (OR 10.1, 95% CI 5.65 - 18.2) and the start of rifampin within 5 days after surgical debridement (OR 1.96, 95% CI 1.08 - 3.65) were predictors of treatment failure. The dosing of rifampin had no effect on outcome.

Conclusions: Our data supports the use of rifampin in acute staphylococcal PJIs treated with surgical debridement, particularly in knees. Immediate start of rifampin after surgical debridement should probably be discouraged, but requires further investigation.
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http://dx.doi.org/10.1093/cid/ciab426DOI Listing
May 2021

The importance of appropriate diagnostics in prosthetic joint infection: letter to the editor of BMC musculoskeletal disorders.

BMC Musculoskelet Disord 2021 03 8;22(1):255. Epub 2021 Mar 8.

Head of Infectious Diseases Department, Hospital Clinic of Barcelona, Barcelona, Spain.

Assessment of a new diagnostic test must be performed against an acceptable and validated standard to allow comparison with other studies. We are concerned that the adoption of lower diagnostic criteria in this paper has contributed to an over-diagnosis of prosthetic joint infection and makes interpretation of the results difficult.
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http://dx.doi.org/10.1186/s12891-021-04117-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7941875PMC
March 2021

Should all hip and knee prosthetic joints be aspirated prior to revision surgery?

Arch Orthop Trauma Surg 2021 Mar 9;141(3):461-468. Epub 2021 Feb 9.

Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands.

Aims: It is essential to exclude a periprosthetic joint infection (PJI) prior to revision surgery. It is recommended to routinely aspirate the joint before surgery. However, this may not be necessary in a subgroup of patients. The aim of our study was to investigate if specific clinical and implant characteristics could be identified to rule out a PJI prior to revision surgery.

Methods: We retrospectively evaluated clinical and implant characteristics of patients who underwent a hip or knee revision surgery between October 2015 and October 2018. Patients were diagnosed with a PJI according to the MSIS diagnostic criteria.

Results: A total of 156 patients were analyzed, including 107 implants that were revised because of prosthetic loosening and 49 because of mechanical failure (i.e. instability, malalignment or malpositioning). No PJI was diagnosed in the group with mechanical failure. In the prosthetic loosening group, 20 of 107 were diagnosed with a PJI (19%). Although there was a significantly lower chance of having a PJI with an implant age of > 5 years combined with a CRP < 5 mg/L, an infection was still present in 3 out of 39 cases (8%).

Conclusion: Implants with solely mechanical failure without signs of loosening and low inflammatory parameters probably do not require a synovial fluid aspiration. These results need to be confirmed in a larger cohort of patients. In case of prosthetic loosening, all joints need to be aspirated before surgery as no specific characteristic could be identified to rule out an infection.
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http://dx.doi.org/10.1007/s00402-021-03791-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7900020PMC
March 2021

The EBJIS definition of periprosthetic joint infection.

Bone Joint J 2021 Jan;103-B(1):18-25

Orthopaedic Hospital Valdoltra, Ankaran, Slovenia.

Aims: The diagnosis of periprosthetic joint infection (PJI) can be difficult. All current diagnostic tests have problems with accuracy and interpretation of results. Many new tests have been proposed, but there is no consensus on the place of many of these in the diagnostic pathway. Previous attempts to develop a definition of PJI have not been universally accepted and there remains no reference standard definition.

Methods: This paper reports the outcome of a project developed by the European Bone and Joint Infection Society (EBJIS), and supported by the Musculoskeletal Infection Society (MSIS) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Implant-Associated Infections (ESGIAI). It comprised a comprehensive review of the literature, open discussion with Society members and conference delegates, and an expert panel assessment of the results to produce the final guidance.

Results: This process evolved a three-level approach to the diagnostic continuum, resulting in a definition set and guidance, which has been fully endorsed by EBJIS, MSIS, and ESGIAI.

Conclusion: The definition presents a novel three-level approach to diagnosis, based on the most robust evidence, which will be useful to clinicians in daily practice. Cite this article: 2021;103-B(1):18-25.
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http://dx.doi.org/10.1302/0301-620X.103B1.BJJ-2020-1381.R1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7954183PMC
January 2021

The impact of surgical strategy and rifampin on treatment outcome in Cutibacterium periprosthetic joint infections.

Clin Infect Dis 2020 Dec 10. Epub 2020 Dec 10.

Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, the Netherlands.

Background: Cutibacterium species are common pathogens in periprosthetic joint infections (PJI). These infections are often treated with β-lactams or clindamycin as monotherapy, or in combination with rifampin. Clinical evidence supporting the value of adding rifampin for treatment of Cutibacterium PJI is lacking.

Materials/methods: In this multicenter retrospective study, we evaluated patients with Cutibacterium PJI. The primary endpoint was clinical success, defined by the absence of infection relapse or new infection within a minimal follow-up of 12 months. We used Fisher's exact tests and Cox proportional hazards models to analyze the effect of rifampin and other factors on clinical success after PJI.

Results: We included 187 patients (72.2% male, median age 67 years) with a median follow-up of 36 months. The surgical intervention was two-stage exchange in 95 (50.8%), one-stage exchange in 51 (27.3%), debridement and implant retention (DAIR) in 34 (18.2%), and explantation without reimplantation in 7 (3.7%). Rifampin was included in the antibiotic regimen in 81 (43.3%) cases. Infection relapse occurred in 28 (15.0%), and new infection in 13 (7.0%) cases. In the time-to-event analysis, DAIR (adjusted HR=2.15, p=0.03) and antibiotic treatment over 6 weeks (adjusted HR=0.29, p=0.0002) significantly influenced treatment failure. We observed a tentative evidence for a beneficial effect of adding rifampin to the antibiotic treatment - though not statistically significant for treatment failure (adjusted HR=0.5, p=0.07) and not for relapses (adjusted HR=0.5, p=0.10).

Conclusions: We conclude that a rifampin combination is not markedly superior in Cutibacterium PJI but a dedicated prospective multicenter study is needed.
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http://dx.doi.org/10.1093/cid/ciaa1839DOI Listing
December 2020

Chronic prosthetic joint infections with a draining sinus. Who should receive suppressive antibiotic treatment?

J Bone Jt Infect 2020 30;6(2):43-45. Epub 2020 Oct 30.

Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.

The benefit of suppressive antibiotic treatment in inoperable patients with a chronic periprosthetic joint infection and a sinus tract is unknown. Some physicians prefer to just let the sinus drain, while others prefer antibiotic treatment. In this viewpoint article we discuss the advantages and disadvantages of suppressive antibiotic treatment in this particular patient group.
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http://dx.doi.org/10.5194/jbji-6-43-2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7648273PMC
October 2020

Clinical implications of increased uptake in bone marrow and spleen on FDG-PET in patients with bacteremia.

Eur J Nucl Med Mol Imaging 2021 05 26;48(5):1467-1477. Epub 2020 Oct 26.

Medical Imaging Center, Departments of Radiology, Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.

Purpose: To investigate which clinical factors and laboratory values are associated with high FDG uptake in the bone marrow and spleen on 2-deoxy-2-[18F]fluoro-D-glucose (FDG) positron emission tomography (PET)/computed tomography (CT) in patients with bacteremia.

Methods: One hundred forty-five consecutive retrospective patients with bacteremia who underwent FDG-PET/CT between 2010 and 2017 were included. Mean standard uptake values (SUV) of FDG in bone marrow, liver, and spleen were measured. Bone marrow-to-liver SUV ratios (BLR) and spleen-to-liver SUV ratios (SLR) were calculated. Linear regression analyses were performed to examine the association of BLR and SLR with age, gender, hemoglobin, leukocyte count, platelets, glucose level, C-reactive protein (CRP), microorganism, days of antibiotic treatment before FDG-PET/CT, infection focus, use of immunosuppressive drugs, duration of hospital stay (after FDG-PET/CT), ICU admission, and mortality.

Results: C-reactive protein (p = 0.006), a cardiovascular or musculoskeletal focus of infection (p = 0.000 for both), and bacteremia caused by Gram-negative bacteria (p = 0.002) were independently and positively associated with BLR, while age (p = 0.000) and glucose level before FDG-PET/CT (p = 0.004) were independently and negatively associated with BLR. For SLR, CRP (p = 0.001) and a cardiovascular focus of infection (p = 0.020) were independently and positively associated with SLR, while age (p = 0.002) and glucose level before FDG-PET/CT (p = 0.016) were independently and negatively associated with SLR.

Conclusion: High FDG uptake in the bone marrow is associated with a higher inflammatory response and younger age in patients with bacteremia. In patients with high FDG uptake in the bone marrow, a cardiovascular or musculoskeletal focus of infection is more likely than other foci, and the infection is more often caused by Gram-negative species. High splenic FDG uptake is associated with a higher inflammatory response as well, and a cardiovascular focus of infection is also more likely in case of high splenic FDG uptake.
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http://dx.doi.org/10.1007/s00259-020-05071-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8113205PMC
May 2021

Relationship between F-FDG Uptake in the Oral Cavity, Recent Dental Treatments, and Oral Inflammation or Infection: A Retrospective Study of Patients with Suspected Endocarditis.

Diagnostics (Basel) 2020 Aug 24;10(9). Epub 2020 Aug 24.

Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, PO 9700 RB Groningen, The Netherlands.

[F]-fluorodeoxyglucose positron emission tomography ([F]FDG PET/CT) has proven to be a useful diagnostic tool in patients with suspected infective endocarditis (IE), but is conflicting in relation to dental procedures.

Questions: Is there a correlation between [F]FDG PET/CT findings, recent dental treatment, and an affected oral cavity? (2) Is there a correlation between infective endocarditis (IE), oral health status, and (extra)cardiac findings on [F]FDG PET/CT?

Methods: This retrospective study included 52 patients. All [F]FDG PET/CT scans were examined visually by pattern recognition using a three-point scale and semi-quantified within the volume of interest (VOI) using SUV.

Results: 19 patients were diagnosed with IE (group 1), 14 with possible IE (group 2), and 19 without IE based on the modified Duke criteria (group 3). No correlation was found between visual PET and SUV and sites of oral inflammation and infection. The visual PET scores and SUV were not significantly different between all groups. A significant difference in the SUV of the valve between all groups was observed.

Conclusions: This study suggests that no correlation exists between the PET findings in the oral cavity and dental treatments or inflammation/infection. No correlation between IE, actual oral health status, and extra-cardiac findings was demonstrated. Additional research is needed to conclude whether [F]FDG PET/CT imaging is a reliable diagnostic modality for oral inflammation and infection sites.
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http://dx.doi.org/10.3390/diagnostics10090625DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7555096PMC
August 2020

How to handle concomitant asymptomatic prosthetic joints during an episode of hematogenous PJI, a multicentre analysis.

Clin Infect Dis 2020 Aug 18. Epub 2020 Aug 18.

Service of Infectious Diseases, Hospital Clínic, University of Barcelona, Barcelona, Spain.

Introduction: Prosthetic joints are at risk of becoming infected during an episode of bacteremia, especially during S. aureus bacteremia. However, it is unclear how often asymptomatic 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: 91 patients with a hematogenous PJI and 108 concomitant prosthetic joints were included. 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 non-infected ones in 67% of cases, and prosthetic knees were affected more often than prosthetic hips (78%).

Conclusion: 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.
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http://dx.doi.org/10.1093/cid/ciaa1222DOI Listing
August 2020

2020 Frank Stinchfield Award: Identifying who will fail following irrigation and debridement for prosthetic joint infection.

Bone Joint J 2020 Jul;102-B(7_Supple_B):11-19

Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

Aims: Failure of irrigation and debridement (I&D) for prosthetic joint infection (PJI) is influenced by numerous host, surgical, and pathogen-related factors. We aimed to develop and validate a practical, easy-to-use tool based on machine learning that may accurately predict outcome following I&D surgery taking into account the influence of numerous factors.

Methods: This was an international, multicentre retrospective study of 1,174 revision total hip (THA) and knee arthroplasties (TKA) undergoing I&D for PJI between January 2005 and December 2017. PJI was defined using the Musculoskeletal Infection Society (MSIS) criteria. A total of 52 variables including demographics, comorbidities, and clinical and laboratory findings were evaluated using random forest machine learning analysis. The algorithm was then verified through cross-validation.

Results: Of the 1,174 patients that were included in the study, 405 patients (34.5%) failed treatment. Using random forest analysis, an algorithm that provides the probability for failure for each specific patient was created. By order of importance, the ten most important variables associated with failure of I&D were serum CRP levels, positive blood cultures, indication for index arthroplasty other than osteoarthritis, not exchanging the modular components, use of immunosuppressive medication, late acute (haematogenous) infections, methicillin-resistant infection, overlying skin infection, polymicrobial infection, and older age. The algorithm had good discriminatory capability (area under the curve = 0.74). Cross-validation showed similar probabilities comparing predicted and observed failures indicating high accuracy of the model.

Conclusion: This is the first study in the orthopaedic literature to use machine learning as a tool for predicting outcomes following I&D surgery. The developed algorithm provides the medical profession with a tool that can be employed in clinical decision-making and improve patient care. Future studies should aid in further validating this tool on additional cohorts. Cite this article: 2020;102-B(7 Supple B):11-19.
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http://dx.doi.org/10.1302/0301-620X.102B7.BJJ-2019-1628.R1DOI Listing
July 2020

A Second Surgical Debridement for Acute Periprosthetic Joint Infections Should Not Be Discarded.

J Arthroplasty 2020 08 26;35(8):2204-2209. Epub 2020 Feb 26.

Department of Orthopaedic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.

Background: In acute periprosthetic joint infections (PJIs), a second surgical debridement (debridement, antibiotics, and implant retention [DAIR]) is generally not recommended after a failed first one. We identified the failure rate of a second DAIR and aimed to identify patients in whom an additional debridement might still be beneficial.

Methods: Patients with acute PJI of the hip or knee and treated with DAIR between 2006 and 2016 were retrospectively evaluated. A second DAIR was routinely performed provided that the soft tissue was intact. Failure of a second DAIR was described as (1) the need for additional surgical intervention to achieve infection control, (2) the need for antibiotic suppressive therapy due to persistent clinical and/or biochemical signs of infection, or (3) PJI related death.

Results: From the 455 cases treated with DAIR, 144 cases underwent a second debridement (34.6%). Thirty-seven cases failed (37/144, 25.7%). The implant needed to be removed in 23 cases (23/144, 16%). Positive cultures during the second DAIR (odds ratio 3.16, 95% confidence interval 1.29-7.74) and chronic renal insufficiency (odds ratio 13.6, 95% confidence interval 2.03-91.33) were independent predictors for failure in the multivariate analysis. No difference in failure was observed between persistent infection with the same microorganism and reinfection with a new microorganism (failure rate 31.6% vs 34.6%, P = .83).

Conclusion: A second DAIR had a low failure rate in our cohort of patients and the implant could be retained in the majority of them. Therefore, a second DAIR should not be discarded in acute PJIs.
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http://dx.doi.org/10.1016/j.arth.2020.02.043DOI Listing
August 2020

Lower Success Rate of Débridement and Implant Retention in Late Acute versus Early Acute Periprosthetic Joint Infection Caused by Staphylococcus spp. Results from a Matched Cohort Study.

Clin Orthop Relat Res 2020 06;478(6):1348-1355

M. Wouthuyzen-Bakker, Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, the Netherlands.

Background: Surgical débridement, antibiotics and implant retention (DAIR) is currently recommended by international guidelines for both early acute (postsurgical) and late acute (hematogenous) periprosthetic joint infections (PJIs). However, due to a different pathogenesis of infection, a different treatment strategy may be needed.

Questions/purposes: (1) Compared with early acute PJIs, are late acute PJIs associated with a higher risk of DAIR failure? (2) When stratified by microorganism, is the higher risk of failure in late acute PJI associated with Staphylocococcus aureus infection? (3) When analyzing patients with S. aureus infection, what factors are independently associated with DAIR failure?

Methods: In this multicenter observational study, early acute and late acute PJIs treated with DAIR were retrospectively evaluated and matched according to treating center, year of diagnosis, and infection-causing microorganism. If multiple matches were available, the early acute PJI diagnosed closest to the late acute PJI was selected. A total of 132 pairs were included. Treatment success was defined as a retained implant during follow-up without the need for antibiotic suppressive therapy.

Results: Late acute PJIs had a lower treatment success (46% [60 of 132]) compared with early acute PJIs (76% [100 of 132]), OR 3.9 [95% CI 2.3 to 6.6]; p < 0.001), but the lower treatment success of late acute PJIs was only observed when caused by Staphylococcus spp (S. aureus: 34% versus 75%; p < 0.001; coagulase-negative staphylococci: 46% versus 88%; p = 0.013, respectively). On multivariable analysis, late acute PJI was the only independent factor associated with an unsuccessful DAIR when caused by S. aureus (OR 4.52 [95% CI 1.79 to 11.41]; p < 0.001).

Conclusions: Although DAIR seems to be a successful therapeutic strategy in the management of early acute PJI, its use in late acute PJI should be reconsidered when caused by Staphylococcus spp. Our results advocate the importance of isolating the causative microorganism before surgery.

Level Of Evidence: Level III, therapeutic study.
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http://dx.doi.org/10.1097/CORR.0000000000001171DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7319375PMC
June 2020

Factors to Consider When Assessing the Diagnostic Accuracy of Synovial Leukocyte Count in Periprosthetic Joint Infection.

J Bone Jt Infect 2019 2;4(4):167-173. Epub 2019 Aug 2.

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

Synovial white blood cell (WBC) count and the percentage of polymorphonuclear leucocytes (PMN%) is one of the diagnostic criteria to diagnose a periprosthetic joint infection (PJI). Although the test is widely available, the diagnostic accuracy of proposed cut-off levels are influenced by several factors, such as: the affected joint, co-morbid conditions, the causative microorganism and the gathering and processing of samples in the laboratory. In this narrative review we provide an overview on how and to what extent these factors can affect the synovial WBC count and PMN% in synovial fluid.
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http://dx.doi.org/10.7150/jbji.34854DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6757010PMC
August 2019

Debridement, Antibiotics, and Implant Retention Is a Viable Treatment Option for Early Periprosthetic Joint Infection Presenting More Than 4 Weeks After Index Arthroplasty.

Clin Infect Dis 2020 07;71(3):630-636

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

Background: The success of debridement, antibiotics, and implant retention (DAIR) in early periprosthetic joint infection (PJI) largely depends on the presence of a mature biofilm. At what time point DAIR should be disrecommended is unknown. This multicenter study evaluated the outcome of DAIR in relation to the time after index arthroplasty.

Methods: We retrospectively evaluated PJIs occurring within 90 days after surgery and treated with DAIR. Patients with bacteremia, arthroscopic debridements, and a follow-up <1 year were excluded. Treatment failure was defined as (1) any further surgical procedure related to infection; (2) PJI-related death; or (3) use of long-term suppressive antibiotics.

Results: We included 769 patients. Treatment failure occurred in 294 patients (38%) and was similar between time intervals from index arthroplasty to DAIR: the failure rate for Week 1-2 was 42% (95/226), the rate for Week 3-4 was 38% (143/378), the rate for Week 5-6 was 29% (29/100), and the rate for Week 7-12 was 42% (27/65). An exchange of modular components was performed to a lesser extent in the early post-surgical course compared with the late course (41% vs 63%, respectively; P < .001). The causative microorganisms, comorbidities, and durations of symptoms were comparable between time intervals.

Conclusions: DAIR is a viable option in patients with early PJI presenting more than 4 weeks after index surgery, as long as DAIR is performed within at least 1 week after the onset of symptoms and modular components can be exchanged.
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http://dx.doi.org/10.1093/cid/ciz867DOI Listing
July 2020

Antibiotic Use in Total Knee Arthroplasty Periprosthetic Joint Infection.

Clin Infect Dis 2020 03;70(6):1259-1260

Service of Infectious Diseases, Hospital Clínic, University of Barcelona, Spain.

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http://dx.doi.org/10.1093/cid/ciz631DOI Listing
March 2020

Timing of implant-removal in late acute periprosthetic joint infection: A multicenter observational study.

J Infect 2019 09 15;79(3):199-205. Epub 2019 Jul 15.

Infectious Diseases Section, Internal Medicine Service, Hospital Italiano de Buenos Aires, Argentina.

Objectives: We evaluated the treatment outcome in late acute (LA) periprosthetic joint infections (PJI) treated with debridement and implant retention (DAIR) versus implant removal.

Methods: In a large multicenter study, LA PJIs of the hip and knee were retrospectively evaluated. Failure was defined as: PJI related death, prosthesis removal or the need for suppressive antibiotic therapy. LA PJI was defined as acute symptoms <3 weeks in patients more than 3 months after the index surgery and with a history of normal joint function.

Results: 445 patients were included, comprising 340 cases treated with DAIR and 105 cases treated with implant removal (19% one-stage revision (n = 20), 74.3% two-stage revision (n = 78) and 6.7% definitive implant removal (n = 7). Overall failure in patients treated with DAIR was 45.0% (153/340) compared to 24.8% (26/105) for implant removal (p < 0.001). Difference in failure rate remained after 1:1 propensity-score matching. A preoperative CRIME80-score ≥3 (OR 2.9), PJI caused by S. aureus (OR 1.8) and implant retention (OR 3.1) were independent predictors for failure in the multivariate analysis.

Conclusion: DAIR is a viable surgical treatment for most patients with LA PJI, but implant removal should be considered in a subset of patients, especially in those with a CRIME80-score ≥3.
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http://dx.doi.org/10.1016/j.jinf.2019.07.003DOI Listing
September 2019

Letter to the Editor regarding Falstie-Jensen et al: "Labeled white blood cell/bone marrow single-photon emission computed tomography with computed tomography fails in diagnosing chronic periprosthetic shoulder joint infection".

J Shoulder Elbow Surg 2019 07;28(7):e250-e251

Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands. Electronic address:

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http://dx.doi.org/10.1016/j.jse.2019.03.025DOI Listing
July 2019

[Prosthetic joint infection].

Ned Tijdschr Geneeskd 2019 05 16;163. Epub 2019 May 16.

LUMC, afd. Infectieziekten, Leiden.

Prosthetic joint infection A prosthetic joint infection (PJI) is a serious complication that can lead to lengthy hospitalization, significant limitations in mobility, and a reduced quality of life. For acute PJI, the aim is to cure the infection whilst retaining the prosthesis; this can be achieved by means of thorough surgical debridement, cleaning of the artificial material, replacement of exchangeable prosthesis parts and adjuvant antibiotic therapy. In cases of chronic PJI, the prosthetic joint needs to be replaced. For patients in whom surgery is not feasible, or who refuse surgical intervention, chronic suppressive antibiotic therapy can be applied if the infection persists. In order to increase the likelihood of a favourable outcome, it is important to take a multidisciplinary approach.
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May 2019

Is Gram staining still useful in prosthetic joint infections?

J Bone Jt Infect 2019 29;4(2):56-59. Epub 2019 Jan 29.

Service of Infectious Diseases, Hospital Clínic, University of Barcelona, Barcelona, Spain.

: is an independent risk factor for DAIR failure in patients with a late acute prosthetic joint infection (PJI). Therefore, identifying the causative microorganism in an acute setting may help to decide if revision surgery should be chosen as a first surgical approach in patients with additional risk factors for DAIR failure. The aim of our study was to determine the sensitivity of Gram staining in late acute PJI. : We retrospectively evaluated all consecutive patients between 2005-2015 who were diagnosed with late acute PJI due to . Late acute PJI was defined as the development of acute symptoms and signs of PJI, at least three months after the index surgery. Symptoms existing for more than three weeks were excluded from the analysis. Gram staining was evaluated solely for synovial fluid. : A total of 52 cases were included in the analysis. Gram staining was positive with Gram positive cocci in clusters in 31 cases (59.6%). Patients with a C-reactive protein (CRP) > 150 mg/L at clinical presentation had a significantly higher rate of a positive Gram stain (30/39, 77%) compared to patients with a CRP ≤ 150 mg/L (4/10, 40%) (p=0.02). A positive Gram stain was not related to a higher failure rate (60.6% versus 57.9%, p 0.85). : Gram staining may be a useful diagnostic tool in late acute PJI to identify PJI. Whether a positive Gram stain should lead to revision surgery instead of DAIR should be determined per individual case.
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http://dx.doi.org/10.7150/jbji.31312DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6470656PMC
January 2019

Obese patients have higher rates of polymicrobial and Gram-negative early periprosthetic joint infections of the hip than non-obese patients.

PLoS One 2019 8;14(4):e0215035. Epub 2019 Apr 8.

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

Background: Obese patients are more likely to develop periprosthetic joint infection (PJI) after primary total joint arthroplasty. This study compared the clinical and microbiological characteristics of non-obese, obese and severely obese patients with early PJI, in order to ultimately optimize antibiotic prophylaxis and other prevention measures for this specific patient category.

Methods: We retrospectively evaluated patients with early PJI of the hip and knee treated with debridement, antibiotics and implant retention (DAIR) between 2006 and 2016 in three Dutch hospitals. Only patients with primary arthroplasties indicated for osteoarthritis were included. Early PJI was defined as an infection that developed within 90 days after index surgery. Obesity was defined as a BMI ≥30kg/m2 and severe obesity as a BMI ≥35kg/m2.

Results: A total of 237 patients were analyzed, including 64 obese patients (27.0%) and 62 severely obese patients (26.2%). Compared with non-obese patients, obese patients had higher rates of polymicrobial infections (60.3% vs 33.3%, p<0.001) with more often involvement of Enterococcus species (27.0% vs 11.7%, p = 0.003). Moreover, severely obese patients had more Gram-negative infections, especially with Proteus species (12.9% vs 2.3%, p = 0.001). These results were only found in periprosthetic hip infections, comprising Gram-negative PJIs in 34.2% of severely obese patients compared with 24.7% in obese patients and 12.7% in non-obese patients (p = 0.018).

Conclusions: Our results demonstrate that obese patients with early periprosthetic hip infections have higher rates of polymicrobial infections with enterococci and Gram-negative rods, which stresses the importance of improving preventive strategies in this specific patient category, by adjusting antibiotic prophylaxis regimens, improving disinfection strategies and optimizing postoperative wound care.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0215035PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6453483PMC
December 2019

Is Routine Urinary Screening Indicated Prior To Elective Total Joint Arthroplasty? A Systematic Review and Meta-Analysis.

J Arthroplasty 2019 07 19;34(7):1523-1530. Epub 2019 Mar 19.

Department of Infectious Diseases, Hospital Clínic of Barcelona, University of Barcelona, IDIBAPS, Barcelona, Spain.

Background: Prosthetic joint infection (PJI) is a serious complication after total joint arthroplasty, and prevention is of great importance. The genitourinary tract is a potential source of bacterial seeding and one that can be easily managed. Despite little supportive evidence, routine urine screening and subsequent treatment before elective surgery in patients without symptoms has found its way into clinical practice in many countries. This systematic review and meta-analysis aims to ascertain whether asymptomatic bacteriuria (ASB) is a risk factor for PJI and if so, whether preoperative antibiotic treatment is effective in reducing its risk.

Methods: PubMed, Ovid Medline, and Cochrane databases were searched using a systematic strategy. Selection of papers was exclusive to include only those which offered information about PJI rate specifically in patients with or without asymptomatic abnormal urinalysis or bacteriuria and/or information on whether ASB patients were preoperatively treated with antibiotics or not to be included in the analysis.

Results: Six-hundred sixty-three papers were screened, and 10 papers were ultimately included (28,588 patients). Results show an increased risk of developing PJI among ASB patients (odds ratio = 3.64, 95% confidence interval = 1.40-9.42). However, most PJI microorganisms are unrelated to those previously found in the urine and preoperative antibiotic therapy does not influence PJI risk (odds ratio = 0.98, 95% confidence interval = 0.39-2.44).

Conclusion: Routine urinary screening prior to elective total joint arthroplasty and treatment of asymptomatic patients is not recommended.
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http://dx.doi.org/10.1016/j.arth.2019.03.034DOI Listing
July 2019

FDG-PET/CT for Detecting an Infection Focus in Patients With Bloodstream Infection: Factors Affecting Diagnostic Yield.

Clin Nucl Med 2019 Feb;44(2):99-106

From the Medical Imaging Center, Departments of Radiology, Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen.

Purpose: To investigate the diagnostic performance of F-fluoro-2-deoxy-D-glucose (FDG) PET/ CT for the detection of an infection focus in patients with a bloodstream infection (BSI) and to identify factors influencing the diagnostic yield of FDG-PET/CT.

Methods: This retrospective single-center study included 185 consecutive patients with a BSI who underwent an FDG-PET/CT scan for the detection of an infection focus between 2010 and 2017. The final diagnosis at hospital discharge was used as reference standard. Diagnostic performance of FDG-PET/CT for the detection of an infection focus was assessed, and logistic regression analyses were performed to identify factors associated with FDG-PET/CT yield.

Results: An infection focus was identified on FDG-PET/CT in 120 (64.8%) of 185 patients. FDG-PET/CT achieved a sensitivity of 80.2%, specificity of 79.6%, positive predictive value of 90.8%, and a negative predictive value of 61.4% for detecting an infection focus in patients with a BSI. Blood cultures positive for enterococci (odds ratio, 0.14; P = 0.019) and days of antibiotic treatment before FDG-PET/CT (odds ratio, 0.94 per day increase; P = 0.014) were statistically significant independent predictors of a lower odds of detecting an infection focus on FDG-PET/CT. In patients who received antibiotics for less than 7 days before FDG-PET/CT, an infection focus was found in 71% (56/79). In patients who received antibiotics for 8 to 14 days before FDG-PET/CT, an infection focus was found in 52% (22/42). After 15 to 21 days of antibiotic treatment, an infection focus was found in 61% (8/13), and for 22 days or more, this declined to 38% (5/13).

Conclusions: FDG-PET/CT is a useful method for detecting an infection focus in patients with BSI. However, longer duration of antibiotic treatment before FDG-PET/CT and bacteremia with enterococci reduce the diagnostic yield of FDG-PET/CT. These factors should be taken into account when considering an FDG-PET/CT scan for this indication.
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http://dx.doi.org/10.1097/RLU.0000000000002381DOI Listing
February 2019

Erysipelas or cellulitis with a prosthetic joint .

J Bone Jt Infect 2018 4;3(4):222-225. Epub 2018 Oct 4.

Department of Infectious Diseases, Hospital Universitario de Bellvitge, IDIBELL, Barcelona, Spain.

We describe a case of a 60-year old male who developed an acute prosthetic joint infection (PJI) of the knee, secondary to erysipelas of the lower leg due to beta-hemolytic Group G streptococci. As it is unknown how often this phenomenon occurs in patients with prosthetic implants and which patients are most prone to develop this complication, we analyzed: i) the incidence of the development of a PJI in these patients and ii) the clinical characteristics of streptococcal PJI during an episode of erysipelas/cellulitis. Based on a retrospective analysis of patients with a prosthetic implant presenting at the emergency department with erysipelas/cellulitis, 1 out of 10 patients developed a PJI. An additional analysis within a multicenter cohort on streptococcal PJI demonstrated in 22 patients that a secondary PJI due to erysipelas/cellulitis mostly develops in young implants (<5 years old). In 20 cases (91%), the skin infection was in the same limb as the joint prosthesis suggesting contiguous spread of bacteria. These data emphasizes the importance of preventive measures to reduce the occurrence of skin infections in patients with prosthetic implants, and if an erysipelas or cellulitis does occur, to monitor patients carefully.
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http://dx.doi.org/10.7150/jbji.25519DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6215988PMC
October 2018