Andreas Stein

Bone and joint infections due to anaerobic bacteria: an analysis of 61 cases and review of the literature

The diagnosis of anaerobic bone and joint infections (BJI) were underestimated before the advent of molecular identification and matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS). We report 61 cases of anaerobic infections based on our 4-year experience with the management of BJI. A total of 75xa0% of cases were post-surgical infections, associated with osteosynthesis devices (65xa0%). Early infections occurred in 27xa0% of cases, delayed infections in 17.5xa0% of cases, and late infections in 55xa0% of cases. We recorded 36 species of 93 anaerobic strains using MALDI-TOF MS (91) and molecular methods (2). We identified 20 strains of Propionibacterium acnes, 13 of Finegoldia magna, six of Peptoniphilus asaccharolyticus, and six of P. harei. Polymicrobial infections occurred in 50 cases. Surgical treatment was performed in 93.5xa0% of cases. The antibiotic treatments included amoxicillin (30xa0%), amoxicillin–clavulanic acid (16xa0%), metronidazole (30xa0%), and clindamycin (26xa0%). Hyperbaric oxygen therapy was used in 17 cases (28xa0%). The relapse rate (27xa0%) was associated with lower limbs localization (pu2009=u20090.001). P. acnes BJI was associated with shoulder (pu2009=u20090.019), vertebra (pu2009=u20090.021), and head flap localization (pu2009=u20090.011), and none of these cases relapsed (pu2009=u20090.007). F. magna BJI was associated with ankle localization (pu2009=u20090.014). Anaerobic BJI is typically considered as a post-surgical polymicrobial infection, and the management of this infection combines surgical and medical treatments. MALDI-TOF MS and molecular identification have improved diagnosis. Thus, physicians should be aware of the polymicrobial nature of anaerobic BJI to establish immediate broad-spectrum antibiotic treatment during the post-surgical period until accurate microbiological results have been obtained.

Dramatic reduction in Clostridium difficile ribotype 027-associated mortality with early fecal transplantation by the nasogastric route: a preliminary report.

Clostridium difficile ribotype 027 (CD027)-associated diarrhea preferentially affects elderly patients and causes a high mortality rate. Fecal microbiota transplantation has become an alternative treatment for recurrent C. difficile infections. An outbreak of CD027 infections has occurred in Marseille since March 2013. From March to November 2013, we treated patients using only antibiotics or fecal microbiota transplantation after at least three relapses. Beginning in November 2013, we performed early transplantation using a nasogastric tube during the first week of infection, in combination with antibiotic treatment. Sixty-one patients with a mean age of 84xa0years were hospitalized, including 42 patients treated only with antibiotics, three with tardive transplantation, and 16 with early transplantation. The patients were comparable in clinical involvement. The global mortality rate was 3/16 (18.75xa0%) among the patients treated by early transplantation and 29/45 (64.4xa0%) among the patients only treated by antibiotics or by tardive transplantation (pu2009<u20090.01). Among these 45 patients, 23 (51xa0%) died at day 31, including 17 who died at day 7. Early fecal transplantation was associated with a significantly reduced mortality rate, with only one patient dead at day 31 (6.25xa0%). In a Cox model, early transplantation was the only independent predictor of survival (hazard ratio 0.18, 95xa0% confidence interval 0.05–0.61, pu2009=u20090.006). Six of the 16 patients (37.5xa0%) needed a second transplantation before symptom resolution. Early fecal microbiota transplantation in combination with antibiotics should be the first-line treatment for CD027 infections.

Emerging role of Raoultella ornithinolytica in human infections: a series of cases and review of the literature.

BACKGROUNDnRaoultella ornithinolytica is known to inhabit aquatic environments. The clinical features and outcomes of human infections caused by R. ornithinolytica have been reported for only a limited number of cases.nnnMETHODSnA retrospective study of cases of infection caused by R. ornithinolytica managed at four university hospital centres during the period before and after the introduction of matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) was performed. The aim was to describe the clinical and microbiological characteristics, treatments, and outcomes.nnnRESULTSnAmong 187 R. ornithinolytica isolates identified for which clinical information was available, 71 were considered colonizers and 116 were pathogenic. A total of 112 cases of R. ornithinolytica infection were identified. Urinary tract infections, gastrointestinal infections, wound and skin infections, and bacteraemia were observed in 36%, 14%, 13%, and 5% of cases, respectively. Associated infections that have been poorly reported, such as respiratory infections, i.e. pneumonia and pleural effusion, were observed in 24% of cases. Additional diseases reported here for the first time included osteomyelitis, meningitis, cerebral abscess, mediastinitis, pericarditis, conjunctivitis, and otitis. The proportion of R. ornithinolytica isolates resistant to antibiotics was found to be relatively high: 4% of isolates were resistant to ceftriaxone, 6% to quinolones, and 13% to co-trimoxazole. The mortality rate related to infection was 5%.nnnCONCLUSIONSnR. ornithinolytica is an underreported, emerging hospital-acquired infection and is particularly associated with invasive procedures. R. ornithinolytica should never be considered simply a saprophytic bacterium that occasionally contaminates bronchial lavage or other deep respiratory samples or surgical sites. Physicians should be aware of the high rates of antimicrobial resistance of R. ornithinolytica isolates so that immediate broad-spectrum antibiotic treatment can be established before accurate microbiological results are obtained.

The microbial epidemiology of breast implant infections in a regional referral centre for plastic and reconstructive surgery in the south of France

BACKGROUNDnBreast implant infections are usually caused by Staphylococcus aureus and coagulase-negative staphylococci. Gram-negative bacilli are rarely reported to be involved in breast implant infections.nnnMETHODSnThirty-seven cases of microbiologically confirmed breast implant infection managed from January 2008 to June 2012 in the study centre were reviewed, including 10 cases from the study centre itself and 27 cases from private clinics in the region.nnnRESULTSnThe prevalence of breast implant infection in the study centre was 0.74% of breast implantation, i.e., 3.23% in breast reconstruction for breast cancer and 0.27% in aesthetic breast augmentation (p=0.0002). Of the 37 cases, 30% had undergone radiotherapy and 11% had undergone a lymph node dissection. S. aureus was identified in 18 cases, Gram-negative bacilli in 10 cases, coagulase-negative staphylococci in eight cases, anaerobic bacteria in eight cases, and streptococci in three cases. Pseudomonas aeruginosa was the second most commonly identified pathogen. Staphylococcus epidermidis was the most frequent coagulase-negative Staphylococcus species. In addition to Propionibacterium acnes and Actinomyces neuii, other facultative and strict anaerobic bacteria have not been reported before, e.g., Bacteroides thetaiotaomicron, Corynebacterium simulans, Dermabacter hominis, Finegoldia magna, and Peptoniphilus harei. Seventy-percent of cases were treated by immediate implant removal. All cases treated only with antibiotics were treated with surgery at the second visit.nnnCONCLUSIONSnThe microbiological epidemiology was noted by an increasing the proportion of Gram-negative bacteria and anaerobic bacteria detected with the advent of MALDI-TOF MS and molecular identification for diagnosis.

Staphylococcus caprae bone and joint infections: a re-emerging infection?

Staphylococcus caprae has been recently classified as a human pathogen, but the incidence of S.xa0caprae in human bone and joint infections (BJIs) is under-reported. In this study, we report 25 cases of S.xa0caprae BJI, and we review the 31 cases published in the literature. Molecular techniques and matrix-assisted laser desorption ionization time-of-flight mass spectrometry improved the identification of clinically relevant S.xa0caprae strains. In this study, 96% of S.xa0caprae BJIs were localized to the lower limbs, and 88% of the cases involved orthopaedic device infections. S.xa0caprae joint prosthesis infections (JPIs), internal osteosynthesis device infections (I-ODIs) and BJIs without orthopaedic device infections were recorded in 60%, 28% and 12% of cases, respectively. Ten (40%) S.xa0caprae BJIs were polymicrobial infections. These infections were associated with past histories of malignancy (pxa00.024). Of the 14 bacterial species related to S.xa0caprae BJI, 57% were staphylococci. I-ODIs were significantly associated with polymicrobial infections (pxa00.0068), unlike JPIs, which were monomicrobial infections (pxa00.0344). Treatment with rifampicin and fluoroquinolone was recorded in 40% of cases. Surgical treatment was performed in 76% of cases, e.g. prosthesis removal (36%), osteosynthesis device removal (24%), and surgical debridement (16%). Thirty perxa0cent of cases were not treated. Relapses were observed mainly in the patients treated by surgical debridement only (pxa00.033). In summary, S.xa0caprae BJI is an underestimated hospital-acquired emerging infection. S.xa0caprae BJI is correlated with infections in orthopaedic devices, which must be removed to control the infection.

Changing trends in the epidemiology of vertebral osteomyelitis in Marseille, France

The incidence and significant morbidity of vertebral osteomyelitis are increasing despite the progress of diagnosis competences. Among the 50 cases of vertebral osteomyelitis managed in our centers over the past 5 years, 84% of the cases were in men. The mean age was 55 years. Sixty-two percent of patients had comorbidities and risk factors: diabetes mellitus (24%), malignancy (16%), intravenous drug use (10%) and alcoholism (4%). A source of infection was identified in 66% of cases, including postvertebral surgery infection (18%) and hematogenous infection (48%). The mean time to diagnosis was 36 days. Back pain were occurred in 90% of cases, fever (70%), neurologic deficits (40%), epidural abscesses (32%), completed vertebral bone destruction (26%) and psoas abscess (12%). A single organism was isolated in 92% of cases. Gram-positive bacteria were identified in 76% of cases, while Gram-negative bacilli (GNB) were found in 18% of cases. The presence of GNB was significantly associated with malignancy (p 0.041). The mean duration of antibiotic therapy was 123 days. Surgical treatment was performed in 41 cases: spinal stabilization (26%), drainage of abscesses (32%) and relief of compression (40%). Residual pain was found in 24% of cases, and neurologic sequelae in 22%. Cervical or thoracic localization was a risk factor for neurologic compromise (p 0.042). The epidemiology of vertebral osteomyelitis has changed; an increase in malignancy that was significantly associated with vertebral osteomyelitis due to GNB has been observed. Our study shows that the rate of neurologic complications remains high despite improved diagnostic capabilities and optimal treatment.

First Real Life Evidence of New Direct-acting Antivirals (DAA) in Co-infected HIV HCV Patients: Better than Ever

TO THE EDITOR—Direct-acting antiviral (DAA)-based anti-hepatitis C virus (HCV) therapies currently provide amazing opportunities to cure almost all HCVpositive patients. However, these results were obtained in clinical trials. We read the points raised by Shafran with interest [1], proposing that all future phase 3 antiHCV clinical trial programmes should include human immunodeficiency virus (HIV)-coinfected participants with HCVmonoinfected patients, because HIV coinfection does not affect sustained

Clinical features and outcome of bone and joint infections with streptococcal involvement: 5-year experience of interregional reference centres in the south of France

Streptococcal bone and joint infections are less common than staphylococcal cases. Few studies have reported the cases with well-identified Streptococcus species. Their clinical features and prognosis are not clearly known to date. Moreover, no treatment regimen has yet been clarified. We reviewed the streptococcal bone and joint infection cases managed in our centres from January 2009 to December 2013. We described the epidemiology, clinical and microbiologic characteristics, treatment approach and outcome. Among the 93 cases, 83% of patients were men with a median age of 60 years, and 90% of patients had comorbidities or risk factors. Bacteraemia occurred in 14% of cases. Serious complications occurred in six patients, including severe sepsis (two cases) and infective endocarditis (two cases). Orthopaedic device infections were observed in 35% of cases, including 17 patients with internal osteosynthesis device infection, 14 with prosthetic joint infection and three with vertebral osteosynthesis device infection. The median time between orthopaedic device implantation and onset of infection was 447 days. Fourteen species of Streptococcus were identified, including 97 isolates using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry and three isolates using molecular identification. The five most represented species included S. agalactiae (37%), S. dysgalactiae (12%), S. anginosus (11%), S. constellatus (10%) and S. pneumoniae (9%). Streptococci isolates were susceptible to amoxicillin, with the exception of one S. mitis isolate. Remission 1 year after the end of treatment was recorded in 83%. One patient died of infection; eight patients had infections that failed to respond to treatment; and seven patients experienced relapse. Twenty patients (22%) had an unfavourable functional outcome, including 19 amputations and one arthrodesis. Five significant prognostic factors associated with an unfavourable clinical outcome were identified, including peripheral neuropathy (p 0.009), peripheral arterial disease (p 0.019), diabetes mellitus (p 0.031), location in the femur (p 0.0036), location in the foot (p 0.0475), osteitis without an orthopaedic device (p 0.041) and infection caused by S. dysgalactiae (p 0.020). The rate of poor outcomes remains high despite the low number of Streptococcus isolates resistant to antibiotics. Some prognostic factors, such as the presence of S. dysgalactiae, are associated with an unfavourable clinical outcome. Antibiotic regimens of streptococcal bone and joint infections are not standardized and need to be further investigated.

Prosthetic joint infection caused by Pasteurella multocida: a case series and review of literature

BackgroundPasteurella multocida is a well-recognized zoonotic agent following dog or cat bites or scratches. Nevertheless, prosthetic joint infection caused by P. multocida are rarely reported.MethodWe report here a series of six cases of prosthetic joint infection caused by P. multocida managed at a referral centre for the treatment of bone and joint infection in southern France. We also reviewed the 26 cases reported in literature.ResultsThe mean age of our cases was 74xa0years [±8.2, range 63–85]. In majority of our cases (5 cases) were associated with knee prostheses and one case with a hip prosthesis. Most of cases occurred after cat or dog scratches or licks or contact. Diagnoses of prosthetic joint infection caused by P. multocida were made by positive cultures of surgical biopsies or needle aspiration. Mean time delay between prosthetic joint implantation and infection onset was 7.6xa0years (±5.12xa0years, range 2–17). Local inflammation, which occurred in all six cases, was the most frequent clinical symptom, followed by pain in five cases, fever and swollen joints in four cases, and a fistula with purulent discharge inside the wound in two cases. The mean time of antibiotic therapy was 8 months. Surgical treatment with prosthesis removal was performed in three cases. Six of our cases were in remission without apparent relapse at 3 years after end of treatment.ConclusionProsthetic joint infections caused by P. multocida usually occur after animal scratches or bites, but can occasionally occur after a short animal lick. These infections are usually resulting from a contiguous infection and localized in the knee. An early antibiotic therapy after surgical debridement could avoid prosthetic withdrawal, notably in elderly patients. Patients with prosthetic joints should be warned that animals are potential sources of serious infection and urgent medical advice should be sought if they are bitten or scratched.

Staphylococcus lugdunensis: a neglected pathogen of infections involving fracture-fixation devices

PurposeCases of fracture-fixation device infection involving Staphylococcus lugdunensis are not frequent. The clinical characteristics and the choice of treatment strategies of these infections are not obviously known to date.MethodsWe performed a review of fracture-fixation device infection involving S. lugdunensis managed by our centres.ResultsAmong the 38 cases of fracture-fixation device infection involving S. lugdunensis, 53% were located in the tibia. Most of our cases (87%) were chronic infections. Purulent discharge, which occurred in 79% of cases, was the most frequent clinical symptom, followed by pain in 63%, local inflammation in 55%, and fever in 37%. Bacteremia and severe sepsis occurred in 10% and 18% of cases, respectively. Four cases (10%) were treated exclusively with antimicrobial treatment alone. Thirty-four cases (89%) were treated with a combination of surgery with antimicrobial therapy including surgical debridement, antibiotics and osteosynthesis device retention in six cases (16%), and osteosynthesis device removal in 27 cases (71%). The mean length of antibiotic treatment was 119xa0days. The relapse rate was high that was not related to selection of resistant strains. Polymicrobial infection had no impact on clinical outcome. A combination of surgery with antimicrobial therapy was identified as a significant prognostic factor associated with remission (pxa0=xa00.042).ConclusionsS. lugdunensis is probably involved in more infections than has been reported. Using appropriate microbiological methods laboratories should routinely identify the species of all coagulase-negative Staphylococci isolates involved in fracture-fixation device infection to better achieve the treatment strategies of fracture-fixation device infection involving S. lugdunensis.