The Role of Synovial Fluid Aspiration in Shoulder Joint Infections

Abstract Background: Joint aspiration with analysis of synovial fluid white blood cell count (WBC) and microbiological culture is a widely established aspect in the diagnosis of shoulder joint infections (SJI). In case of a two stage revision for SJI, joint aspiration before re-/implantation of an total shoulder arthroplasty (TSA) was used to rule out persistent infection for years but its value is under debate. Shoulder specific data on all aspects is rare. The current study aims to answer the following research questions: Joint aspiration has an insufficient predictive value in the diagnosis of SJI in (1) initial workup and (2) before definite arthroplasty with polymethylmethacrylate (PMMA)-Spacer in place. Methods: This retrospective evaluation investigates 35 patients that were treated for SJI with a two staged implantation of a TSA after debridement and implantation of an PMMA-Spacer. Joint aspirations were performed preoperatively (PA) and before re‑/implantation of the prosthesis while spacer was in place (interstage aspiration, IA). Samples were taken for microbiological culture and analysis of WBC. Sensitivity and specificity were calculated with reference to intraoperative microbiological samples. Receiver Operating Characteristic (ROC), Area-Under-Curve analysis (AUC) and calculation of the Youden index were performed to find optimum cut-off for WBC. Results: The sensitivity of microbiological cultures from PA was 58.3% and the specificity was 88.9%. The mean WBC was 27 800 leucocytes/mm3 (range 400-96 300). The maximum Youden index (0.857) was a cut-off of 2600 leucocytes/mm³ with a sensitivity of 85.7% and a specificity of 100.0%. The sensitivity and specificity of IA were 0.0% and 88.5%, respectively. Conclusions: PA is likely to miss Cutibacteria spp. Cuand CoNS and cannot rule out infection for sure. However, we recommend PA for its advantages of targeted antibiotic therapy in case of germ identification. Empiric antibiotic therapy should therefore cover these bacteria even if aspiration showed negative microbiological cultures. In contrast, diagnostic value of IA does not qualify for routine use. Trial registration: The study was approved by the ethic committee of the author`s institution (registration number 235/16-mk). The patients gave written informed consent to their inclusion in the study.

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Better choice of the type of specimen used for untargeted metagenomic sequencing in the diagnosis of periprosthetic joint infections

The Bone & Joint Journal ◽

10.1302/0301-620x.103b5.bjj-2020-0745.r1 ◽

2021 ◽

Vol 103-B (5) ◽

pp. 923-930

Author(s):

Renke He ◽

Qiaojie Wang ◽

Jin Wang ◽

Jin Tang ◽

Hao Shen ◽

...

Keyword(s):

Synovial Fluid ◽

Sensitivity And Specificity ◽

Joint Infection ◽

Diagnostic Value ◽

Single Type ◽

Molecular Technique ◽

Metagenomic Sequencing ◽

Musculoskeletal Infection ◽

Joint Infections ◽

Generation Sequencing

Aims As a proven and comprehensive molecular technique, metagenomic next-generation sequencing (mNGS) has shown its potential in the diagnosis of pathogens in patients with periprosthetic joint infection (PJI), using a single type of specimen. However, the optimal use of mNGS in the management of PJI has not been explored. In this study, we evaluated the diagnostic value of mNGS using three types of specimen with the aim of achieving a better choice of specimen for mNGS in these patients. Methods In this prospective study, 177 specimens were collected from 59 revision arthroplasties, including periprosthetic tissues, synovial fluid, and prosthetic sonicate fluid. Each specimen was divided into two, one for mNGS and one for culture. The criteria of the Musculoskeletal Infection Society were used to define PJI (40 cases) and aseptic failure (19 cases). Results The sensitivity and specificity of mNGS in the diagnosis of PJI were 95% and 94.7%, respectively, for all types of specimen. The sensitivity and specificity were 65% and 100%, respectively, for periprosthetic tissues, 87.5% and 94.7%, respectively, for synovial fluid, and 92.5% and 94.7%, respectively, for prosthetic sonicate fluid. The mNGS of prosthetic sonicate fluid outperformed that for other types of specimen in the rates of detection of pathogens (84.6%), sequencing reads (> ten-fold) and the rate of genome coverage (> five-fold). Conclusion mNGS could serve as an accurate diagnostic tool in the detection of pathogens in patients with a PJI using three types of specimen. Due to its superior perfomance in identifying a pathogen, mNGS of prosthetic sonicate fluid provides the most value and may partly replace traditional tests such as bacteriological culture in these patients. Cite this article: Bone Joint J 2021;103-B(5):923–930.

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Ultrasound Doppler and tenosynovial fluid analysis in tenosynovitis

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2020-216927 ◽

2020 ◽

Vol 79 (7) ◽

pp. 908-913

Author(s):

Fawad Aslam ◽

Bryant R England ◽

Amy Cannella ◽

Veronika Sharp ◽

Lily Kao ◽

...

Keyword(s):

Logistic Regression ◽

Synovial Fluid ◽

Sensitivity And Specificity ◽

White Cell Count ◽

Diagnostic Utility ◽

Fluid Analysis ◽

Inflammatory Conditions ◽

Rheumatic Conditions ◽

The Mean ◽

Rule Out

ObjectiveTo assess Doppler ultrasound (US) and tenosynovial fluid (TSF) characteristics in tenosynovitis within common rheumatic conditions, as well as their diagnostic utility.MethodsSubjects with tenosynovitis underwent Doppler US and US-guided TSF aspiration for white cell count (WCC) and crystal analysis. Tenosynovial Doppler scores (DS) were semiquantitatively graded. TSF WCC and DS were compared using Kruskal-Wallis tests and logistic regression between non-inflammatory conditions (NIC), inflammatory conditions (IC) and crystal-related conditions (CRC). Receiver operating curves, sensitivity and specificity assessed the ability of WCC and DS to discriminate IC from NIC.ResultsWe analysed 100 subjects from 14 sites. The mean age was 62 years, 65% were female, and the mean TSF volume was 1.2 mL. Doppler signal was present in 93.7% of the IC group and was more frequent in IC than in NIC group (OR 6.82, 95% CI 1.41 to 32.97). The TSF median WCC per 109/L was significantly higher in the IC (2.58, p<0.001) and CRC (1.07, p<0.01) groups versus the NIC group (0.38). A TSF cut-off of ≥0.67 WCC per 109/L optimally discriminated IC versus NIC with a sensitivity and specificity each of 81.3%. In the IC group, 20 of 48 (41.7%) subjects had a TSF WCC <2.00 per 109/L.ConclusionsA negative DS helps rule out IC in tenosynovitis, but a positive DS is non-specific and merits TSF testing. Unlike synovial fluid, a lower TSF WCC better discriminates IC from NIC. US guidance facilitates aspiration of minute TSF volume, which is critical for diagnosing tenosynovial CRC.

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How well does synovial fluid gram staining correlate with cultures in native joint infections?

Orthopedic Reviews ◽

10.4081/or.2019.8156 ◽

2019 ◽

Vol 11 (4) ◽

Author(s):

Herbert Gbejuade ◽

Mohamed Elsakka ◽

Lucy Cutler

Keyword(s):

Synovial Fluid ◽

Sensitivity And Specificity ◽

Culture Technique ◽

Gram Negative Bacteria ◽

Gram Stain ◽

Gram Negative ◽

Gram Positive Bacteria ◽

Joint Infections ◽

Gram Staining ◽

Low Sensitivity

To evaluate the sensitivity and specificity of Gram staining of synovial fluid aspirated from native joints suspected to be infected, we reviewed results of synovial fluid Gram stain and cultures. The sensitivity and specificity of the synovial Gram stain were then calculated. From the 1067 consecutive synovial fluid samples evaluated, 830 samples fulfilled the set criteria. From these 830 synovial fluid samples, organisms were detected by culture technique in only 100 samples; most of which were Gram-positive bacteria (78%). The other 22% comprised Gram-negative bacteria, Fungi and a mixture of growth. Of these, concomitant Gram stain test revealed sensitivity and specificity of 17.0% and 99.7% respectively. Our study demonstrates that the Gram stain technique has low sensitivity in detecting organisms in presumed native joint infections. Our findings demonstrate that the Gram stain test is an unreliable investigation in diagnosing native joint infections.

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Synovial Fluid Aspiration Should Not Be Routinely Performed during the Two-Stage Exchange of the Knee

BioMed Research International ◽

10.1155/2018/6720712 ◽

2018 ◽

Vol 2018 ◽

pp. 1-8 ◽

Cited By ~ 1

Author(s):

Sebastian P. Boelch ◽

Magnus Roth ◽

Joerg Arnholdt ◽

Maximilian Rudert ◽

Martin Luedemann

Keyword(s):

Synovial Fluid ◽

Blood Cell ◽

Sensitivity And Specificity ◽

Pathogen Detection ◽

Joint Infection ◽

Youden Index ◽

Blood Cell Count ◽

Two Stage ◽

Synovial Fluid Culture ◽

Fluid Culture

Purpose. Detection of infection persistence during the two-stage exchange of the knee for periprosthetic joint infection is challenging. Synovial fluid culture (SFC) and synovial white blood cell count (SWBCC) before joint reimplantation are widespread diagnostic means for this indication. The sensitivity and specificity of SFC and of SWBCC for infection persistence before planned reimplantation were evaluated. Methods. 94 two-stage exchanges of the knee with synovial fluid aspiration performed after a drug holiday of at least 14 days and before reimplantation or spacer exchange (planned reimplantation) were retrospectively analyzed. Only cases with at least 3 intraoperative samples at planned reimplantation were included. SFC and SWBCC were compared to pathogen detection (SFC(culture)/SWBCC(culture)) and to histopathological signs of infection persistence (SFC(histo)/SWBCC(histo)) from intraoperative samples at planned reimplantation. For SFC, the sensitivity and specificity were calculated. For SWBCC, the optimal cut-off value with its sensitivity and specificity was calculated with the Youden-Index. Results. Sensitivity and specificity of SFC(culture) were 0.0% and 98.9%. Sensitivity and specificity of SFC(histo) were 3.4% and 100%. The optimal cut-off value for SWBCC(culture) was 4450 cells/μl with a sensitivity of 50.0% and a specificity of 86.5%. The optimal cut-off value for SWBCC(histo) was 3250 cells/μl with a sensitivity of 35.7% and a specificity of 92.9%. Conclusion. The detection of infection persistence remains challenging and a consented approach is lacking. The results do not warrant the routine performance of SFC during the two-stage exchange at the knee. SWBCC can be used to confirm infection persistence at high cut-offs, but they only occur in few patients and are therefore inappropriate for the routine use.

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Novel therapeutic interventions towards improved management of septic arthritis

BMC Musculoskeletal Disorders ◽

10.1186/s12891-021-04383-6 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Jian Wang ◽

Liucai Wang

Keyword(s):

Antibiotic Therapy ◽

Septic Arthritis ◽

Clinical Success ◽

Treatment Protocol ◽

Current Treatment ◽

Therapeutic Interventions ◽

Medical Emergency ◽

Success Rates ◽

Joint Infections ◽

Novel Therapeutic

AbstractSeptic arthritis (SA) represents a medical emergency that needs immediate diagnosis and urgent treatment. Despite aggressive treatment and rapid diagnosis of the causative agent, the mortality and lifelong disability, associated with septic arthritis remain high as close to 11%. Moreover, with the rise in drug resistance, the rates of failure of conventional antibiotic therapy have also increased. Among the etiological agents frequently isolated from cases of septic arthritis, Staphylococcus aureus emerges as a dominating pathogen, and to worsen, the rise in methicillin-resistant S. aureus (MRSA) isolates in bone and joint infections is worrisome. MRSA associated cases of septic arthritis exhibit higher mortality, longer hospital stay, and higher treatment failure with poorer clinical outcomes as compared to cases caused by the sensitive strain i.e methicillin-sensitive S. aureus (MSSA).In addition to this, equal or even greater damage is imposed by the exacerbated immune response mounted by the patient’s body in a futile attempt to eradicate the bacteria. The antibiotic therapy may not be sufficient enough to control the progression of damage to the joint involved thus, adding to higher mortality and disability rates despite the prompt and timely start of treatment. This situation implies that efforts and focus towards studying/understanding new strategies for improved management of sepsis arthritis is prudent and worth exploring.The review article aims to give a complete insight into the new therapeutic approaches studied by workers lately in this field. To the best of our knowledge studies highlighting the novel therapeutic strategies against septic arthritis are limited in the literature, although articles on pathogenic mechanism and choice of antibiotics for therapy, current treatment algorithms followed have been discussed by workers in the past. The present study presents and discusses the new alternative approaches, their mechanism of action, proof of concept, and work done so far towards their clinical success. This will surely help to enlighten the researchers with comprehensive knowledge of the new interventions that can be used as an adjunct therapy along with conventional treatment protocol for improved success rates.

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Which Type of Empiric Antibiotic Therapy is Appropriate? A 20-Year Retrospective Study of Bloodstream Infections in Childhood Cancer

Infectious Diseases and Therapy ◽

10.1007/s40121-021-00427-5 ◽

2021 ◽

Author(s):

Andreas Meryk ◽

Gabriele Kropshofer ◽

Caroline Bargehr ◽

Miriam Knoll ◽

Benjamin Hetzer ◽

...

Keyword(s):

Retrospective Study ◽

Antibiotic Therapy ◽

Childhood Cancer ◽

Bloodstream Infections ◽

Empiric Antibiotic Therapy ◽

Empiric Antibiotic

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Successful de-escalation antibiotic therapy using cephamycins for sepsis caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae bacteremia: A sequential 25-case series

Open Medicine ◽

10.1515/med-2020-0103 ◽

2020 ◽

Vol 15 (1) ◽

pp. 782-786

Author(s):

Tsukasa Kuwana ◽

Junko Yamaguchi ◽

Kosaku Kinoshita ◽

Satoshi Hori ◽

Shingo Ihara ◽

...

Keyword(s):

Septic Shock ◽

Antibiotic Therapy ◽

Vital Signs ◽

Apache Ii ◽

Empiric Antibiotic Therapy ◽

Apache Ii Score ◽

Beta Lactamase ◽

Extended Spectrum Beta Lactamase ◽

Escalation Therapy ◽

Extended Spectrum

AbstractCarbapenems are frequently used to treat infections caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E), but carbapenem-resistant Enterobacteriaceae bacteria are a clinical concern. Although cephamycins (cefmetazole; CMZ) have been shown to be effective against mild cases of ESBL-E infection, data on their use for severe ESBL-E infections with sepsis or septic shock remain scarce. Herein, we discuss a de-escalation therapy to CMZ that could be used after empiric antibiotic therapy in ICU patients with sepsis or septic shock caused by ESBL-E bacteremia. A sequence of 25 cases diagnosed with sepsis or septic shock caused by ESBL-E bacteria was evaluated. The attending infectious disease specialist physicians selected the antibiotics and decided the de-escalation timing. The median SOFA (Sequential Organ Failure Assessment) and APACHE II (Acute Physiology and Chronic Health Evaluation II) severity scores were 8 and 30; the rate of septic shock was 60%. Infections originated most frequently with urinary tract infection (UTI) (56%) and Escherichia coli (85%). Eleven patients were de-escalated to CMZ after vital signs were stable, and all survived. No patients died of UTI regardless of with or without de-escalation. The median timing of de-escalation antibiotic therapy after admission was 4 days (range, 3–6 days). At the time of de-escalation, the median SOFA score fell from 8 to 5, the median APACHE II score from 28 to 22, and the rate of septic shock from 55% to 0%. We conclude that for sepsis in UTI caused by ESBL-E bacteremia, de-escalation therapy from broad-spectrum antibiotics to CMZ is a potential treatment option when vital signs are stable.

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Purple urine bag syndrome is a rare manifestation of bacteriuria on bladder catheter: case report

African Journal of Urology ◽

10.1186/s12301-021-00191-5 ◽

2021 ◽

Vol 27 (1) ◽

Author(s):

Othmane Mohib ◽

Thomas Roland ◽

Margot Fontaine ◽

France Laurent ◽

Camelia Rossi

Keyword(s):

Antibiotic Therapy ◽

Rare Complication ◽

Total Duration ◽

Empiric Antibiotic Therapy ◽

Healthcare Team ◽

Urine Ph ◽

Urine Retention ◽

Bladder Catheter ◽

Purple Urine Bag Syndrome ◽

Purple Urine

Abstract Background Purple urine bag syndrome (PUBS) is a complication of bacterial colonisation of bladder catheters in which urine turns purple in the tubing, as well as in the catheter bag. This rare phenomenon can be very worrisome and stressful for the patients and their families, as well as for the healthcare team taking care of them. Recognising this complication is essential in order to avoid misdiagnosis and erroneous treatment. We report a case of PUBS in a 71-year-old female patient. Case presentation A 71-year-old woman with previous medical history of schizophrenia was admitted to the emergency department for anorexia and suspicion of psychotic decompensation. Acute urine retention and rectal faecal impaction were clinically suspected and confirmed by bladder ultrasound and rectal examination, respectively. The patient underwent bladder catheterisation as well as a rectal enema. The day after her admission, our medical team was approached by the nurse in charge of the patient because of purple urine in her catheter bag and tubing. The diagnosis of PUBS was made with the help of the Oxford urine chart. A dipstick urinalysis revealed alkaline urine (pH = 8), and the urine culture was subsequently positive for Proteus mirabilis, which is sensitive to quinolones, beta-lactams and nitrofurantoin. The bladder catheter was changed. The patient received empiric antibiotic therapy with Levofloxacin 500 mg once daily. After obtaining the antibiogram, the targeted antibiotic therapy was adapted with oral Cefuroxime 500 mg three times a day for a total duration of seven days of antibiotic therapy. There was no recurrence of purple urine. Conclusion PUBS is a rare complication of bacteriuria, which induces a purple colouration of the tubing as well as the catheter bag. It is a simple spot diagnosis, as there is no other known cause of purple urine. This is why we believe that the Oxford urine chart represents a very interesting and easily accessible tool to help clinicians to investigate any abnormal urine colour.

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