C-reactive protein may misdiagnose prosthetic joint infections, particularly chronic and low-grade infections

Aims The aim of this study was to determine the prevalence and characteristics of C-reactive protein (CRP)-negative prosthetic joint infection (PJI) and evaluate the influence of the type of infecting organism on the CRP level. Patients and Methods A retrospective analysis of all PJIs affecting the hip or knee that were diagnosed in our institution between March 2013 and December 2016 was performed. A total of 215 patients were included. Their mean age was 71 years (sd 11) and there were 118 women (55%). The median serum CRP levels were calculated for various species of organism and for patients with acute postoperative, acute haematogenous, and chronic infections. These were compared using the Kruskal–Wallis test, adjusting for multiple comparisons with Dunn’s test. The correlation between the number of positive cultures and serum CRP levels was estimated using Spearman correlation coefficient. Results Preoperative CRP levels were normal (< 10 mg/l) in 77 patients (35.8%) with positive cultures. Low-virulent organisms were isolated in 66 PJIs (85.7%) with normal CRP levels. When grouping organisms by species, patients with an infection caused by Propionibacterium spp., coagulase-negative staphylococci (CNS), and Enterococcus faecalis had significantly lower median serum CRP levels (5.4 mg/l, 12.2 mg/l, and 23.7 mg/l, respectively), compared with those with infections caused by Staphylococcus aureus and Streptococcus spp. (194 mg/l and 89.3 mg/l, respectively; p < 0.001). Those with a chronic PJI had statistically lower median serum CRP levels (10.6 mg/l) than those with acute postoperative and acute haematogenous infections (83.7 mg/l and 149.4 mg/l, respectively; p < 0.001). There was a significant correlation between the number of positive cultures and serum CRP levels (Spearman correlation coefficient, 0.456; p < 0.001). Conclusion The CRP level alone is not accurate as a screening tool for PJI and may yield high false-negative rates, especially if the causative organism has low virulence. Aspiration of the joint should be used for the diagnosis of PJI in patients with a chronic painful arthroplasty, irrespective of CRP level. Cite this article: Bone Joint J 2018;100-B:1482–86.

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Is Gram staining still useful in prosthetic joint infections?

Journal of Bone and Joint Infection ◽

10.7150/jbji.31312 ◽

2019 ◽

Vol 4 (2) ◽

pp. 56-59 ◽

Cited By ~ 1

Author(s):

Marjan Wouthuyzen-Bakker ◽

Noam Shohat ◽

Marine Sebillotte ◽

Cédric Arvieux ◽

Javad Parvizi ◽

...

Keyword(s):

Revision Surgery ◽

Joint Infection ◽

Individual Case ◽

Gram Stain ◽

Reactive Protein ◽

Joint Infections ◽

Gram Staining ◽

Causative Microorganism ◽

Prosthetic Joint ◽

Prosthetic Joint Infections

Abstract. Introduction: Staphylococcus aureus 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 S. aureus PJI.Material and methods: We retrospectively evaluated all consecutive patients between 2005-2015 who were diagnosed with late acute PJI due to S. aureus. 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.Results: 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).Conclusion: Gram staining may be a useful diagnostic tool in late acute PJI to identify S. aureus PJI. Whether a positive Gram stain should lead to revision surgery instead of DAIR should be determined per individual case.

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Assessment of a Multiplex Serological Test for the Diagnosis of Prosthetic Joint Infection: a Prospective Multicentre Study

Journal of Bone and Joint Infection ◽

10.7150/jbji.42076 ◽

2020 ◽

Vol 5 (2) ◽

pp. 89-95 ◽

Cited By ~ 2

Author(s):

Pascale Bémer ◽

Céline Bourigault ◽

Anne Jolivet-Gougeon ◽

Chloé Plouzeau-Jayle ◽

Carole Lemarie ◽

...

Keyword(s):

Negative Predictive Value ◽

Predictive Value ◽

Serological Test ◽

Bacterial Species ◽

Joint Infection ◽

C Reactive Protein ◽

Reactive Protein ◽

Prosthetic Joint ◽

Prosthetic Joint Infections ◽

Cutibacterium Acnes

Abstract. Introduction: The diagnosis of prosthetic joint infections (PJIs) can be difficult in the chronic stage and is based on clinical and paraclinical evidence. A minimally invasive serological test against the main pathogens encountered during PJI would distinguish PJI from mechanical loosening.Methods: We performed a prospective, multicentre, cross-sectional study to assess the contribution of serology in the diagnosis of PJI. Over a 2-year period, all patients undergoing prosthesis revision were included in the study. A C-reactive protein assay and a serological test specifically designed against 5 bacterial species (Staphylococcus aureus, S. epidermidis, S. lugdunensis, Streptococcus agalactiae, Cutibacterium acnes) were performed preoperatively. Five samples per patient were taken intraoperatively during surgery. The diagnosis of PJI was based on clinical and bacteriological criteria according to guidelines.Results: Between November 2015 and November 2017, 115 patients were included, 49 for a chronic PJI and 66 for a mechanical problem. Among patients with PJI, a sinus tract was observed in 32.6% and a C-reactive protein level ≥10 mg/L in 74.5%. The PJI was monomicrobial in 43 cases (targeted staphylococci, 24; S. agalactiae, 1; C. acnes, 2; others, 16), and polymicrobial in 6 cases (12.2%). Sensitivity, specificity, positive predictive value and negative predictive value were 75.0%, 82.1%, 58.3% and 90.8%, respectively, for targeted staphylococci. Specificity/negative predictive value was 97.3%/100% for S. agalactiae and 83.8% /96.9% for C. acnes.Conclusions: The serological tests are insufficient to affirm the diagnosis of PJI for the targeted bacteria. Nevertheless, the excellent NPV may help clinicians to exclude PJI.

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Detection of low-grade prosthetic joint infections using 99mTc-antigranulocyte SPECT/CT: initial clinical results

European Journal of Nuclear Medicine and Molecular Imaging ◽

10.1007/s00259-010-1431-3 ◽

2010 ◽

Vol 37 (9) ◽

pp. 1751-1759 ◽

Cited By ~ 65

Author(s):

Vera Graute ◽

Markus Feist ◽

Sebastian Lehner ◽

Alexander Haug ◽

Peter Ernst Müller ◽

...

Keyword(s):

Clinical Results ◽

Low Grade ◽

Joint Infections ◽

Prosthetic Joint ◽

Prosthetic Joint Infections

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Experience With the Use of the MicroDTTect Device for the Diagnosis of Low-Grade Chronic Prosthetic Joint Infections in a Routine Setting

Frontiers in Medicine ◽

10.3389/fmed.2021.565555 ◽

2021 ◽

Vol 8 ◽

Author(s):

Camille Kolenda ◽

Jérôme Josse ◽

Cécile Batailler ◽

Allison Faure ◽

Alice Monteix ◽

...

Keyword(s):

Treatment Time ◽

Prosthetic Material ◽

Low Grade ◽

Microbiological Diagnosis ◽

Conventional Culture ◽

Joint Infections ◽

Prosthetic Joint ◽

Prosthetic Joint Infections ◽

Cutibacterium Acnes ◽

Commercial Device

Background: In prosthetic joint infections (PJIs), identification of the causative microorganisms is critical to successfully adapt and optimize treatment. However, microbiological diagnosis of PJIs remains a challenge notably because bacteria are embedded in biofilm adhered to the prosthetic material. Recently, dithiothreitol (DTT) treatment of prosthesis has been proposed as a new strategy to release bacteria from biofilm and to improve the yield of microbiological diagnosis. In this study, we evaluated the interest of a commercial device using DTT, the MicroDTTect system (Heraeus, Hanau, Germany), for the diagnosis of low-grade chronic PJIs, compared to the conventional culture of periprosthetic tissue (PPT) samples.Methods: Twenty patients undergoing a surgery procedure for removal of prosthetic material because of a suspicion of low-grade PJI without pre-operative microbiological documentation were included (NCT04371068). Bacteriological results using the fluid obtained after prosthesis treatment with the MicroDTTect system were compared to results obtained with conventional culture of PPT samples.Results: All the bacteria considered as responsible for PJIs recovered from culture of PPT samples were also detected using the MicroDTTect device. For one patient, an additional bacterial isolate (Staphylococcus haemolyticus) suspected to be involved in a polymicrobial PJI was identified using DTT treatment. Time to positivity of the cultures was also reduced using the MicroDTTect system, notably in case of Cutibacterium acnes infection. However, probable bacterial contaminants were found (MicroDTTect system, n = 5; PPT samples, n = 1).Conclusion: This study showed that DTT treatment of the prosthetic component using the MicroDTTect device could improve the microbiological diagnosis of low-grade PJIs.

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Staphylococcus saccharolyticus Associated with Prosthetic Joint Infections: Clinical Features and Genomic Characteristics

Pathogens ◽

10.3390/pathogens10040397 ◽

2021 ◽

Vol 10 (4) ◽

pp. 397

Author(s):

Bo Söderquist ◽

Mastaneh Afshar ◽

Anja Poehlein ◽

Holger Brüggemann

Keyword(s):

Aseptic Loosening ◽

Normal Skin ◽

Low Grade ◽

Pathogenic Potential ◽

Long Term Outcome ◽

Joint Infections ◽

Prosthetic Joint ◽

Prosthetic Joint Infections ◽

Cutibacterium Acnes

The anaerobic coagulase-negative staphylococcal species Staphylococcus saccharolyticus is a member of the normal skin microbiota. However, S. saccharolyticus is rarely found in clinical specimens and its pathogenic potential is unclear. The clinical data of prosthetic hip (n = 5) and shoulder (n = 2) joint implant-associated infections where S. saccharolyticus was detected in periprosthetic tissue specimens are described. The prosthetic hip joint infection cases presented as “aseptic” loosening and may represent chronic, insidious, low-grade prosthetic joint infections (PJIs), eventually resulting in loosening of prosthetic components. All cases were subjected to one-stage revision surgery and the long-term outcome was good. The shoulder joint infections had an acute onset. Polymicrobial growth, in all cases with Cutibacterium acnes, was found in 4/7 patients. All but one case were treated with long-term administration of beta-lactam antibiotics. Whole-genome sequencing (WGS) of the isolates was performed and potential virulence traits were identified. WGS could distinguish two phylogenetic clades (clades 1 and 2), which likely represent distinct subspecies of S. saccharolyticus. Little strain individuality was observed among strains from the same clade. Strains of clade 2 were exclusively associated with hip PJIs, whereas clade 1 strains originated from shoulder PJIs. It is possible that strains of the two clades colonize different skin habitats. In conclusion, S. saccharolyticus has the potential to cause PJIs that were previously regarded as aseptic loosening of prosthetic joint devices.

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Diagnostični protokol za obravnavo okuženih sklepnih vsadkov

Slovenian Medical Journal ◽

10.6016/zdravvestn.1296 ◽

2015 ◽

Vol 84 (6) ◽

Author(s):

Alen Mlekuž ◽

Rihard Trebše ◽

Rene Mihalič ◽

Vesna Levašič

Keyword(s):

Absolute Number ◽

Low Grade ◽

Joint Infections ◽

Orthopedic Surgeons ◽

Prosthetic Joint ◽

Prosthetic Joint Infections ◽

Early Failures ◽

Increased Sensitivity ◽

To Come ◽

Ongoing Infection

Infection is becoming the most important as well as the most devastating mechanism of prosthetic joint failure. The incidence is increasing due to increased sensitivity of orthopedic surgeons for this diagnosis, better diagnostics, and because the absolute number of operated patients is increasing and because more often very sick, debilitated, and immunocompromised patients are operated on. The trend shows the incidence to further increase in the years to come. The diagnosis may be very easy in case of high grade processes, but also extremely difficult in low grade infections. Misdiagnosing infection leads to repeat early failures and revisions that are distressing for patients as well as for surgeons. To avoid failures related to misdiagnosed prosthetic joint infections a step-wise algorithm of action is proposed and the diagnostic strength of the steps discussed. The key point is to select the potential candidates to define the possibility of an ongoing infection and then to select the tools to strengthen the suspicion. The further procedures base on the analysis of the pseudo-synovial fluid obtained by aspiration. The diagnostic conclusions form the basis for considered treatment decisions.

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