Infection. Arthrocentesis: Cell count Differential Culture. Infection and associated microorganism(s) confirmed

Transcription

1 Painful joint History and examination Radiograph of affected joint Erythrocyte sedimentation rate C-reactive protein Infection No infection suspected Arthrocentesis: Cell count Differential Culture Stop Infection suspected Infection and associated microorganism(s) confirmed No infection suspected Surgery Surgery Stop Intraoperative inspection Histopathology Tissue cultures (3 6) Sonication of prosthesis (if removed) for semiquantitative cultures Figure 2.1. Algorithm for the diagnosis of periprosthetic joint infection. Bone and Joint Infections: From Microbiology to Diagnostics and Treatment, First Edition. Edited by Werner Zimmerli John Wiley & Sons, Inc. Published 2015 by John Wiley & Sons, Inc.

2 Joint pain History and examination Radiograph of affected joint Erthrocyte sedimentation rate C-reactive protein Infection suspected No infection suspected Arthrocentesis: Cell count Differential Culture Microscopic examination for crystals Stop Figure 2.2. Algorithm for the diagnosis of native joint arthritis % < Age (years) Figure 5.1. Age distribution of children with septic arthritis [5].

3 Sternoclavicular 0.1% Shoulder 4.7% Acromioclavicular 0.1% Metacarpal 0.1% Elbow 14.0% Wrist 4.4% Interphalangeal 0.5% Sacroiliac 0.6% Hip 22.2% Metatarsal 0.4% Knee 39.6% Ankle 13.3% Figure 5.2. Anatomical distribution of 781 septic joints diagnosed in 725 children [5].

4 Presumptive skeletal system infections n =131 Blood culture vial Culture positive n = 59 (45.0%) Culture negative n = 72 (55.0%) K. kingae n =17 (28.8%) Others n = 42 (71.2%) Conventional PCR with universal probes followed by sequencing n =61 K. kingae n =16 (26.2%) Others n = 5 (8.2%) Negative n =40 (65.6%) Total K. kingae: 39/131 (29.8%) Real-time PCR with K. kingae-specific probes n =40 K. kingae n = 6 (15.0%) Figure 5.3. Combined use of the blood culture vial technique and nucleic acid amplification assays for diagnosing Kingella kingae arthritis [18].

5 Clinical picture Arthritis Improvement + Laboratory work-up CRP Gram-stain NAAA Cultures AS susceptibility CRP<2 mg/dl Empiric antibiotic therapy (IV) Day 1 2 Specific antibiotic therapy (IV) Day 3 4 Specific antibiotic therapy (oral) Day 10 Figure 5.4. Shortened protocol for guiding antibiotic therapy in uncomplicated pediatric septic arthritis [52, 55, 65]. AB, antibiotic; CRP, C-reactive protein; NAAA, nucleic acid amplification assays.

6 Suspected septic arthritis MRSA >10% of Staphylococcus aureus Yes No Clindamycin resistance in MRSA: <10% Clindamycin resistance in MRSA: 10 25% Clindamycin resistance in MRSA: > 25% Clindamycin Vancomycin or clindamycin or cotrimoxazole Vancomycin or cotrimoxazole First-generation cephalosporin or BLRBL a or clindamycin Figure 5.5. Initial administration of antibiotics based on the local prevalence of antibiotic resistance in Staphylococcus aureus [67]. a betalactamase-resistant betalactam.

7 Manifestation Acute hematogenous Early postinterventional Condition of implant Stable Unstable Condition of soft tissue Intact or slightly damaged Moderately or severely damaged Not qualifying for retention Culture from synovial fluid or hematoma Growth No growth Susceptibility to antimicrobial agents with activity against surfaceadhering microorganisms Yes No Surgical procedure Debridement with retention Suction drainage Antimicrobial treatment Figure 9.1. Treatment algorithm of acute hematogenous and early postinterventional PJI. Modified from Ref. 30.

8 Patients not qualifying for implant retention Condition of soft tissue Intact or slightly damaged Moderately or severely damaged Abscess Sinus tract Modifying circumstances Difficult-to-treat microorganism: Small colony variants Multidrug resistant microorganisms, especially quinolone-resistant Gram-negative bacilli Enterococcus spp. Fungi General condition or surgical risk: Debilitated Bedridden High risk for anaesthesia Underlying problems: Severe immunosuppression Active intravenous drug use No functional improvement by exchange of the implant Surgical procedure One-stage exchange Suction drainage Antimicrobial treatment Two-stage exchange with long interval (8 weeks) Suction drainage No spacer Antimicrobial treatment Long-term suppressive antimicrobial treatment Implant removal without replacement Suction drainage Antimicrobial treatment Two-stage exchange with short interval (2 4 weeks) Suction drainage Spacer Antimicrobial treatment Figure 9.2. Treatment algorithm for patients with PJI not qualifying for implant retention. Modified from Ref. 30.

9 Figure 9.3. Vacuum-assisted closing (VAC) system. Clinical picture of a VAC system covering the open wound. After VAC removal the femoral component of the TKA was visible. LE RH 0 Figure Arthrocentesis of the elbow through a dorso-radial approach. Landmarks are the olecranon (O), the lateral epicondylus (LE), and the radial head (RH). While the elbow is held in approximately 135 of flexion, a 22-gauge needle should enter in the middle of a triangle formed by the lateral epicondyle, the radial head, and the tip of the olecranon.

10 Figure A 61-year-old patient with chronic periprosthetic ankle joint infection. Two months after implantation, he presented with a swollen, tender ankle joint and a sinus tract. The implant was removed, five samples were obtained, and a spacer was implanted. S. aureus grew in all biopsy samples and in sonicated fluid culture from the implant. Figure A 52-year-old patient with acute hematogenous PAJI. Fourteen months after implantation, the right ankle was suddenly erythematous, swollen, and tender.

11 (a) (b) Figure A 62-year-old woman with an exogenous chronic PAJI. (a) Lateral view of the left ankle joint, showing osteolysis around the tibial component (arrow). (b) SPECT/CT showing a significant signal uptake surrounding both implant components. The signal uptake is most around the tibial component (arrow). (a) (b) Figure A 20-year-old man with hematogenous vertebral osteomyelitis due to Salmonella enterica subsp enterica Tennessee. (a) Magnetic resonance imaging (MRI) T1 with gadolinium 5 weeks after episode with diarrhea. No disk enhancement is visible (arrow). (b) MRI T1 with gadolinium 11 weeks after episode with diarrhea and after 6 weeks of adequate antimicrobial therapy. Inflammation and destruction of intervertebral disk is visible (arrow).

12 (a) (b) Figure A 38-year-old IV drug addict who regularly injected heroin dissolved in lemon juice. He had a history of backache for several weeks when he presented with low-grade fever and immobilizing back pain. Biopsy of vertebra Th10 revealed Candida albicans in the culture. (a) gibbus due to severe ventral destruction of vertebra Th10. (b) plain radiograph of thoracic gibbus of the same patient. Figure External orifice of a sinus tract on the calve/femur with maceration of the skin. Image is the property of Geneva University Hospitals and is displayed with the permission of the patient.

13 Figure Transcutaneous bone biopsy of the metatarso-phalangeal joint of the fifth ray on the right foot in a diabetic foot patient; the trocard is introduced through a noninfected skin area opposite to the ulcer. Courtesy of Dr. Eric Beltrand, Department of Orthopedic Surgery Dron Hospital Tourcoing F France. (a) (b) Figure (a) Clinical picture of a diabetic patient with a chronic ulcer of the plantar surface with regard to the second metatarsal head. (b) Radiological signs of osteomyelitis on plain X-rays of the left foot in the same patient. The red arrow indicates joint destruction.

14 Figure A 28-year-old man with a 6-month history of painful swelling of the right lower jaw after tooth extraction. Anaerobic cultures of tissue biopsies revealed Actinomyces israelii and Fusobacterium sp. Figure Prepared instrument set for biopsy sampling. Separate instruments (forceps, knife, curette or bone nibbler) and transport tubes are used for each biopsy sample.

15 (a) (b) (c) (d) Figure A 22-year-old man with chronic implant-associated osteomyelitis after a Gustilo Anderson grade IIIB open tibia fracture. (a) Anteroposterior and lateral radiographs of a fragmented tibial fracture with an intramedullary nail in situ, taken 14 weeks after injury. (b) Wound discharge, indicating chronic infection, 7 months after primary intervention. (c) Stabilization of the fracture with an Ilizarov external fixator. (d) Final X-ray and clinical assessment at 34-month follow-up.

16 (a) (b) Figure (a) Sternal wound 10 days after median sternotomy in a patient who developed fever. (b) After the breasts were moved aside, purulent discharge was visible. (a) (b) Figure (a) An extensive mediastinal wound in a patient with chronic PSTMO and infected costal cartilage. (b) Despite meticulous debridement, the vitality of the costae is suboptimal. Complete resection cannot be performed because of thorax instability. Picture courtesy of Dr. M. Shafighi.