Aim

This study aimed to evaluate the impact on length of hospital stay from dedicated infectious diseases input for orthopaedic infection patients compared to sporadic infection specialist input.

Aim. Culture negative (CN) prosthetic joint infections (PJI) account for approximately 10% of all PJIs and present significant challenges for clinicians. We aimed to explore the significance of CN PJI within a large prospective cohort study, and to compare their characteristics and outcomes with culture positive cases. Methods. The Prosthetic joint Infection in Australia and New Zealand Observational (PIANO) study is a prospective, binational, multicentre observational cohort study conducted at 27 hospitals between July 2014 and December 2017. We compared baseline characteristics and outcomes of all patients with culture negative (CN) prosthetic joint infection (PJI) from the PIANO cohort with culture positive (CP) cases. “Treatment success” was defined as absence of clinical or microbiological signs of infection, no need for ongoing antibiotics, and no need for revision or resection arthroplasty since the end of the initial treatment. We also describe PJI diagnostic criteria in the CN cohort and apply internationally recognised PJI diagnostic guidelines. Results. Of the 650 patients eligible for inclusion, 55 (8.5%) were CN and 595 were CP. Compared with the CP cohort, CN patients were more likely to be female [32 (58.2%) vs 245 (41.2%); p=0.02], involve the shoulder joint [5 (9.1%) vs. 16 (2.7%); p=0.03] and have a lower mean C-reactive protein (142 mg/L vs. 187 mg/L; p=0.02). Overall, outcomes were superior in CN patients, with culture negativity an independent predictor of treatment success at 24 months (aOR 3.78; 95%CI 1.65 – 8.67). Of the 55 CN cases meeting Infectious Diseases Society of America (IDSA) diagnostic criteria, 45 (82%) met European Bone and Joint Infection Society (EBJIS) criteria (probable or definite) and 39 (71%) met the 2013 Musculoskeletal Infection Society (MSIS) criteria. Conclusions. Culture negativity is an independent predictor of treatment success in PJI. It is unclear whether this is because some of them are not actually infections, or for other reasons such as lower bacterial load or earlier effective antibiotic treatment. Diagnostic criteria for PJI vary substantially in their sensitivity, with MSIS criteria being the least sensitive. Acknowledgements. This work is being presented on behalf of the broader PIANO investigators and the Australasian Society for Infectious Diseases Clinical Research Network. The PIANO study received seed funding from Heraeus Medical and the John Hunter Hospital Charitable Trust Fund

Abstract. Background. Distinction between foot and ankle wound healing complications as opposed to infection is crucial for appropriate allocation of antibiotic therapy. Our aim was to evaluate the diagnostic accuracy of white cell count (WCC) and C-reactive protein (CRP) as diagnostic tools for this distinction in the non-diabetic cohort. Methods. Data were reviewed from a prospectively maintained Infectious Diseases Unit database of 216 patients admitted at Leicester University Hospitals – United Kingdom between July 2014 and February 2020 (68 months). All diabetic patients were excluded. For the infected non-diabetic included patients, we retrospectively retrieved the inflammatory markers (WCCs and CRP) at the time of presentation. Values of CRP 0–10 mg/L and WCC 4.0–11.0 ×109 /L were considered normal. Results. 25 patients met our inclusion criteria. Infections were confirmed microbiologically with positive intra-operative culture results. 7 (28%) patients with foot osteomyelitis (OM), 11 (44%) with ankle OM, 5 (20%) with ankle septic arthritis, and 2 (8%) patients with post-surgical wound infection were identified. Previous bony surgery was identified in 13 (52%) patients. 21 (84%) patients did have raised inflammatory markers while 4 (16%) patients failed to mount an inflammatory response even with subsequent debridement and removal of metalwork. CRP sensitivity was 84%, while WCC sensitivity was only 28%. Conclusion. CRP had good sensitivity, whereas WCC is a poor inflammatory marker in the detection of such cases. In presence of a clinically high level of suspicion of foot or ankle infection, a normal CRP should not rule out the diagnosis of OM

Aim. Prosthetic joint infection (PJI) due to Candida spp. is a severe complication of arthroplasty but is little reported. This study describes Candida PJI epidemiology, management, and outcome. Method. We performed a retrospective, observational multinational study with support of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID). Patients diagnosed with PJI due to Candida spp. between 1990 and 2021 were included. Demographic, clinical, laboratory, imaging, medical/surgical treatment, and outcome data were collected within a standardized database. Treatment failure was defined either as a Candida infection recurrence, superinfection, or death due to infection. Results. Data from 151 patients across 18 centers were analyzed. Mean age was 69.5 ± 13.1yo, 78 (51.7%) patients were male, and 21 (13.9%) were immunosuppressed. Site of infection included hip (55.0%), knee (41.7%), shoulder (2.6%), and femur (0.7%). Twenty-five (16.6%) patients were febrile, and 58 (38.4%) had fistula. Mean number of previous surgeries on the same anatomical site was 3.3±2.3. Surgeries were DAIR (33.8%), one-stage exchange (19.9%), two-stage exchange (39.1%), and implant removal (6.0%). Candida species identified were C. albicans (60.3%), C. parapsilosis (26.5%), C. glabrata (7.3%), and C. tropicalis (5.3%). Co-infection with bacteria was found in 69 (45.7%) cases. Fluconazole (62.9%) and caspofungin (14.6%) were the main antifungal agents prescribed for 148.6 ± 167.5 days. Favorable outcome was found in 54/144 (37.5%) cases. Failure was associated with the number of previous surgeries (OR 1.249, 95%CI 1.061–1.469; p-value=0.007), while treatment by fluconazole was associated with cure (OR 0.336, 95%CI 0.160–0.707; p-value=0.004). Conclusions. This study provides epidemiologic and outcome data on Candida PJIs. Although poor overall, the prognosis did not seem associated with immunosuppression, type of surgery, fungal species or treatment duration

Aim. The aim of the study was to assess the accuracy of the alpha defensin lateral flow test for diagnosis of periprosthetic joint infection (PJI) using an optimized diagnostic algorithm and three classification systems. In addition, we compared the performance with synovial fluid leukocyte count, the most sensitive preoperative test. Method. In this prospective multicenter study we included all consecutive patients with painful prosthetic hip and knee joints undergoing diagnostic joint aspiration. Alpha defensin lateral flow test was used according to manufacturer instructions. The following diagnostic criteria were used to confirm infection: Musculoskeletal Infection Society (MSIS), Infectious Diseases Society of America (IDSA) and Swiss orthopedics and Swiss Society of Infectious Diseases (SOSSID). In the latter, PJI was confirmed when at least one of following criteria applied: macroscopic purulence, sinus tract, positive cytology of joint aspirate (>2000 leukocytes/μl or >70% granulocytes), histological proof of acute inflammation in periprosthetic tissue, positive culture (from aspirate, tissue or sonication fluid). Infection was classified as chronic, if symptom duration was more than 3 weeks or if infection manifested after more than 1 month after surgery. The sensitivity and specificity of the alpha defensin lateral flow test and leukocyte count in synovial fluid were calculated and compared using McNemar Chi-square test. Results. Of 151 included patients evaluated for painful prosthetic joints (103 involved knees, 48 hips), the median patient age was 69 years (range, 41–94 years) and 75 patients were female. Systematically evaluating the included patients according to the different diagnostic criteria, MSIS and IDSA revealed both 33 patients with PJI (22%), whereas SOSSID disclosed 47 septic failures (31%), among them 36 chronic infections (77%). Sensitivity of the test was 79% when applying MSIS criteria, 70% with IDSA criteria and 57% with SOSSID criteria. Specificity ranged from 96% (IDSA) to 98% (MSIS) and 99% (SOSSID). Applying the most stringent definition criteria (SOSSID), leukocyte count showed significantly higher sensitivity than the alpha defensin lateral flow test (91% vs. 57%, p<0.001), especially in chronic infections (88% vs. 48%, p<0.001.) In acute infections, both tests detected all infection cases. Processing turnaround time was shorter in Alpha defensin lateral flow test than automated leukocyte count (10 min vs. 2–4 hours). Conclusions. Semi-quantitative alpha defensin test was rapid and highly specific for diagnosing PJI (> 95%). However, sensitivity was limited, especially when applying definition criteria including also low grade infections (SOSSID criteria). Therefore, the alpha defensin lateral flow test does not allow a reliable exclusion of PJI, especially not in chronic infections but may be used as confirmatory test

Aim. Diagnosing periprosthetic joint infections (PJI) can be very challenging, especially infections caused by low virulence microorganisms. No single test with a 100% accuracy is available yet. Hence, different infection definitions were introduced to improve the diagnostic confidence and quality of research articles. Due to constant developments in this field, infection definitions are adopted continuously. The aim of our study was to find the most sensitive currently available infection definition among three currently used criteria (International Consensus Meeting – criteria 2018 (ICM), Infectious Diseases Society of America - criteria 2013 (IDSA), and European Bone and Joint Infection Society – criteria 2021 (EBJIS)) for the diagnosis of PJI. Method. Between 2015 and 2020, patients with an indicated revision surgery due to septic or aseptic failure after a total hip or knee replacement were included in this retrospective analysis of prospectively collected data. A standardized diagnostic workup was done in all patients. The components of the IDSA-, ICM-, and EBJIS- criteria for the diagnosis of PJI were identified in each patient. Results. Overall, 206 patients (hip: n=104 (50%); knee: n=102 (50%)) with a median age of 74 years (IQR 65 – 80y) were included. 101 patients (49%) were diagnosed with PJI when using the EBJIS- criteria. Based on the IDSA- and ICM- criteria, 99 patients (48%, IDSA) and 86 patients (42%, ICM) were classified as septic. Based on all three criteria, 84 cases (41%) had an infection. 15 septic cases (n=15/206; 7%) were only identified by the IDSA- and EBJIS- criteria. In 2 patients (n=2/206, 1%), an infection was present based on only the ICM and EBJIS criteria. No case was classified as infected by one infection definition alone. A statistically significant higher number of inconclusive cases was observed when the ICM criteria (n=30/206; 15%) were used in comparison to the EBJIS criteria (likely infections: n=16/206; 8%) (Fisher's exact test, p=0.041). The EBJIS definition showed a better preoperative performance in comparison to the other two definitions (p<0.0001). Conclusions. The most sensitive infection definition seems to be the novel EBJIS– criteria covering all infections diagnosed by the IDSA- and ICM-criteria without detecting any further infection. In addition, less inconclusive (infection likely) cases were detected by the EBJIS-criteria in comparison with the ICM-criteria reducing the so called ‘grey zone’ significantly which is of utmost importance in clinical routine

Aim. Daptomycin plus fosfomycin combination therapy is a valuable strategy for treating staphylococcal osteoarticular infections. Considernig that each gram of fosfomycin contains 330 mg of sodium, electrolytic imbalance due to sodium overload could pose safety issues, especially in the cardiopatic patients and/or in the frail elderly. The aim of this study was to compare the efficacy of using reduced vs. standard daily dose fosfomycin in combination with daptomycin in a cohort of patients with osteoarticular infections. Method. This analysis included adult patients with osteoarticular infections admitted to the Infectious Diseases Unit of our University hospital in the period Nov 2022 – Feb 2024 and who were treated with daptomycin (8-10 mg/kg/daily) plus 24h-continuous infusion (CI) fosfomycin at the standard-dose of 16 g daily (standard-dose group) or at the reduced-dose of 8-12 g daily (reduced-dose group). All the patients underwent therapeutic drug monitoring (TDM) of fosfomycin for granting a pharmacodynamic target attainment of 24h-area under the concentration-time curve over minimum inhibitory concentration (AUC24h/MIC) >95 against Staphylococcus aureus with an MIC value up to 32 mg/L and of 70%t>MIC. Estimated glomerular filtration rate (eGFR) was assessed at each TDM session. Patient clinical outcome was assessed. Results. The standard- and the reduced-dose groups included 43 (29 males, 67.4%) and 21 (11 males, 52.4%) patients, respectively. No differences in median age (54 vs. 63 years, p=36), weight (80 vs. 76 kg, p=0.13) and type of diagnosis [prosthetic joint infections (16 vs. 29, p=0.38), osteomyelitis (2 vs. 9, p=0.72), septic arthritis (3 vs. 3, p=0.39) and spondilodiscitis (0 vs. 2, p=1.0)] were observed between the two groups. Median eGFR was similar in the standard vs. the reduced-dose group (109 vs. 98 mL/min/1.73m2, p=0.004). In the reduced-dose group, CI fosfomycin was administerd at 8 and 12 g/daily in 12 and 9 patients, respectively. There was no difference between the standard- and reduced-dose groups in attainment of the pharmacodynamic targets of AUC24h/MIC>95 (41/43 vs. 20/21, p=1.0), of 70%t>MIC (43/43 vs. 21/21 p=1.0) and of clinical cure (39/43 vs. 19/21, p=1.0). Conclusions. Combination therapy of 8-10 mg/kg/daily daptomycin plus 8-12 g/daily CI fosfomycin may be as effective as that of 8-10 mg/kg/daily daptomycin plus 16 g/daily CI fosfomycin. The fosfomycin reduced-dose strategy allows to decrease the daily sodium load by 25-50% compared to the standard dose, thus reducing the risk of cardiac adverse events. TDM may be a valuable strategy for individualizing fosfomycin dose in patients with osteoarticular infections

Aim. Debridement and implant retention (DAIR) is a valuable option for treating periprosthetic joint infection (PJI), provided that the criteria of the Infectious Diseases Society of America guidelines are fulfilled. The inflammation caused by infection and the surgical impact of DAIR may influence implant stability. In this study, we investigated the sequelae of DAIR on implant survival after total hip arthroplasty (THA). Method. THAs from our database implanted between 1984 and 2016 were included in a retrospective double-cohort study. THAs were exposed (DAIR cohort) or not exposed to DAIR (control cohort). The control cohort comprised patients matched 3:1 to the DAIR cohort. The outcome—implant failure over time—was evaluated for (i) revision for any reason, (ii) aseptic loosening of any component, and (iii) radiographic evidence of loosening. Results. Fifty-seven THAs (56 patients) were included in the DAIR cohort and 170 THAs (168 patients) in the control cohort. The mean follow-up periods in the DAIR and control cohorts were 6.1 (SD 4.7) and 7.8 (SD 5.5) years, respectively. During follow-up, 20 (36%) patients in the DAIR cohort and 54 (32%) in the control cohort died after a mean of 4.1 (SD 4.7) and 7.2 (SD 5.4) years, respectively. Revision for any reason was performed in 9 (16%) DAIR THAs and 10 (6%) control THAs (p = 0.03) and for aseptic loosening of any component in 5 (9%) DAIR THAs and 8 (5%, p = 0.32) control THAs, respectively. Radiological analysis included 56 DAIR THAs and 168 control THAs. Two (4%) stems and 2 (4%) cups in the DAIR cohort and 7 (4%) and 1 (0.6%) in the control cohort, respectively, demonstrated radiological signs of failure (p = 1). Conclusions. THAs exposed to DAIR were revised for any reason more frequently than were THAs in the control cohort. The difference in revisions for aseptic loosening was not statistically significant. There was no statistically significant difference in radiographic evidence of loosening of any component between cohorts

Aim. Apart from other biomarkers isolated in the synovial fluid, alpha-defensin appears to be a promising diagnostic tool to confirm a periprosthetic joint infection (PJI) in the hip or knee. The purpose of this study was to evaluate the sensitivity and specificity of an alpha defensin lateral flow (ADLF) test compared to usual standard classifications in the diagnostic management of PJI. Method. This investigation was set up as a multicenter prospective cohort study. Synovial fluid was obtained by means of joint aspiration or intra-operative tissue biopsies. A presumptive PJI diagnosis was made according to criteria outlined by the Musculoskeletal Infection Society (MSIS), the Infectious Diseases Society of America (IDSA) and the European Bone and Joint Infection Society (EBJIS). The intention to treat by the surgeon was logged. Sensibility and specificity for the ADLF test was plotted for each aforementioned diagnostic algorithm. Spearman correlations between all scores were analyzed. Multiple logistic regression was used to determine the contribution of independent variables to the probability of PJI. Results. Hundred thirty-six patients with a painful arthroplasty were assessed for infection and rated by the treating surgeon as potentially infected or not on the basis of clinical and laboratory information. According to the EBJIS criteria sixty-eight patients were deemed infected, fifty according to the IDSA criteria, forty-one according to the MSIS criteria and forty according to the ADLF test. However, the sensitivity of ADLF test was 87.8% for MSIS, 70% for IDSA and 55.8% for EBJIS. The specificity of ADLF test was between 94% – 97%. Good correlation was observed between synovial fluid culture and ADLF test (r = 0.73). Low to excellent correlations between the ADLF test and the EBJIS (r = 0.58), IDSA (r = 0.68), and MSIS score (r = 0.84) were observed. The surgeon's intention to treat correlated well with the MSIS score (r = 0.86), and moderately with the EBJIS (r = 0.59). Conclusions. ADLF test sensibility was variable, but its specificity was excellent. Most of the cases, not retained by MSIS but classified by EBJIS as infected, got a negative microbiological result. Considering an accepted 20% negative microbiological result rate in PJI diagnostic, EBJIS is clearly overestimating the number of infected cases. MSIS score correlates with the surgeon intention to treat and ADLF test

In spite of its incidence decreasing to 1% nowadays, prosthesis-related infections remain a research, diagnostic, therapeutic and cost-related problem. Early diagnosis, selection of an appropriate surgical strategy, accurate identification of the responsible microorganisms and construction of an appropriate antibiotic regimen are essential elements of any management strategy. Our study aim was firstly to compare the diagnostic accuracy of conventional periprosthetic tissue culture and culture of fluid derived from vortexing and bath sonication of the explanted hardware and secondly to investigate the role of possible metabolic factors affecting the sensitivity of the sonication method. We investigated 70 patients undergoing revision hip or knee arthroplasty because of loosening of the prostheses, at our institution, between October 2011 and November 2013. Patients’ medical history and demographic characteristics were recorded. We compared the culture of samples obtained by sonication of explanted hip and knee prostheses with conventional culture of periprosthetic tissue for the microbiological diagnosis of prosthetic-joint infection. Infectious Diseases Society of America (IDSA) Guidelines were used for the definition of prosthetic-joint infection. Thirty-two patients had septic loosening and 38 aseptic loosening (48 hip prostheses and 22 knee prostheses). The sensitivity of sonication fluid culture was 81.25% and the sensitivity of conventional tissue cultures was 56.25% (p-value = 0.043). The sensitivity of the sonication method was statistically higher in obese, diabetic patients, with age above 60, in uncemented arthroplasties and in arthroplasties because of primary osteoarthritis (p-values < 0.05). The sonication method represents a reliable test for the diagnosis of prosthetic – joint infections with a greater sensitivity than the conventional periprosthetic tissue cultures, especially in obese, diabetic patients, with age above 60, in uncemented arthroplasties and in arthroplasties because of primary osteoarthritis

Aim. Propionibacterium acnes is an emerging pathogen especially in orthopedic implant infection. Interestingly, we previously reported a difference in the distribution of the clades involved in spine versus hip or knee prosthetic infection. To date, no study has previously explored the direct impact and close relationship of P. acnes on bone cells according to their own genetic background. The aim of this study was to investigate this interaction of P. acnes clinical strains involved in spine material infections, arthroplasty infections and acne lesions with bone cells. Method. From a large collection of 88 P. acnes clinical isolates collected between January 2003 and December 2014, a subset of 11 isolates was studied. Four isolates were recovered from spine infections, two from prosthetic infections (knee and hip), three from acne lesions and two reference strains (ATCC11827 and ATCC6919). Implant-associated infections were confirmed according to Infectious Diseases Society of America guidelines for bone and joint infections. Multi-Locus Sequence Typing (MLST) was carried out on all isolates as described by Lomholt et al. PLoS ONE 2010. Bacterial internalization experiments with MG63 osteosarcoma cells were adapted from Crémet et al. Pathog Dis 2015. Results. Among the nine clinical isolates, three isolates belonged to clonal complexes (CCs) 18; three to CC28 and three to CC36. ATCC isolates belonged to CC18. Bacterial internalization experiments revealed that CC36 P. acnes strains were less invasive than CC18 and CC28 P. acnes strains towards osteoblasts (mean percentage of internalized bacteria (< 0.01% for the CC36 P. acnes strains versus more than 1% for the CC18 and CC28 P. acnes strains). Surprisingly, the ATCC11827 CC18 P. acnes strain exhibited invasiveness similar to CC36 isolates. Conclusions. Evasion mechanism observed for CC36 P. acnes isolates could allow this clade to leave the site of infection, disseminate into deeper tissue layers and beget arthroplasty infection. Inside the deeper tissue, close to the material, the local immune defect fosters the low-grade infections observed with P. acnes clinical strains. On the another hand, for CC18 et CC28 clades, mostly involved in spine infection, the internalization process observed could allow these clades to escape from the numerous immune cells located under the skin and generate an infection locally, favored by the spine instrumentation close to the skin, especially during long spine surgeries

Propionibacterium acnes is an emerging pathogen especially in orthopedic implant infection. Aim of this study was to investigate P. acnes phylogeny and to screen for virulence factors among a large collection of clinical isolates involved in spine material infections, arthroplasty infections and acne lesions. 88 P. acnes clinical isolates were collected between January 2003 and December 2014 at Nantes University Hospital (France). Fifty-eight isolates came from spine infections, 14 from prosthetic infections (knee, hip or shoulder), 14 from acne lesions and two reference strains (ATCC11827 and ATCC6919). Implant associated infections were confirmed using Infectious Diseases Society of America criteria for bone and joint infections. Phylotypes and Multi-Locus Sequence Typing (MLST) was carried out on all isolates as described by Lomholt et al. All isolates were tested by established PCR-based assays for 21 putative virulence factor genes characteristic of P. acnes. MLST analysis revealed an association between clonal complexes (CCs) and origin of P. acnes isolates (p = 0,027). Regarding CCs distribution between different origins, CC36 and phylotype II P. acnes isolates are more frequently observed in prosthetic joint infections. On the other hand, CC18 (IA) and CC28 (IB) P. acnes isolates are more frequently involved in spine infections and acne lesions. Among all virulence factors screened, hyaluronate lyase gene was only present in CC36 and phylotype II P acnes isolates. Other virulence factors were present in all isolates, whatever their origin or CC. Regarding molecular typing results, P. acnes involved in spine infections seem to have a skin origin (same CC as isolates from acne lesion). Interestingly, the origin of prosthetic joint infection isolates seems different and they all carry one more virulence factor. Hyaluronate lyase (Hyl) is a major surface protein of P. acnes with potential antigenetically variable properties that might be essential for P. acnes virulence. Increased tissue permeability caused by the action of hyaluronidase on the extracellular matrix appears to play a role in wound infections, pneumonia, and other sepsis such as bacteremia and meningitis. It could be also take a prominent part in P. acnes prosthetic joint infection pathogenesis

The management of chronic osteomyelitis is fraught with difficulties; a multi-disciplinary team approach is recommended for optimum outcome. Thorough debridement, dead space management and organism targeted antibiotic therapy the gives best clinical results. Calcium sulphate beads impregnated with antibiotic is an absorbable option for prolonged local antibiotic elution and dead space management. This study aims to analyse the early results of single stage management of osteomyelitis with antibiotic impregnated calcium sulphate beads. Following surgical debridement, calcium sulphate impregnated typically with tobramycin and/or vancomycin is inserted to obliterate the dead space. Intravenous antibiotics – typically teicoplanin and piperacillin-tazobactam – are administered until culture results permit rationalisation to narrow spectrum agents. Patients are followed up in Infectious Diseases and Orthopaedic clinics for a period of 12 months and discharged if quiescence is achieved. We conducted a retrospective analysis of our prospective database to identify patients treated with our single stage protocol for chronic osteomyelitis. We excluded patients that had (1) less than 6 months of follow up, (2) incomplete metal-ware removal, (3) patients lost to follow up. Fourteen patients (9 men, 5 women) with mean age of 41 (16–73) years and mean follow up of 9 (6–12) months were included in study. Eleven patients had previous surgeries involving internal fixation; the rest were primary osteomyelitis. Seven patients had washouts and removal of metal-ware procedures for osteomyelitis prior to referral to the bone infection service. Clinical, radiographic, and laboratory (microbiological, biochemical and haematological) methods were used to monitor response to treatment. Cierney-Mader classification determined that 8 patients were classed as type A (normal hosts); 4 as BS (systemically compromised); 2 as BLS (locally and systemically compromised). Anatomic analysis suggested 7 were Type 1 (medullary osteomyelitis); the remaining 7 were type 3 (localised disease). Five patients were staged IA; three each staged IIIA and IIIBS; and one each staged IBs, IBLS, IIIBLS. Staphylococcus Aureus was the commonest causative organism. Follow up radiograph monitoring indicated absorption of the beads by 3 months. There has been no evidence of recurrence based on clinical, radiographic and blood based parameters in all patients. Short-term results of single stage osteomyelitis treatment with calcium sulphate beads impregnated with antibiotics are promising

Septic arthritis is a medical emergency that can lead to significant morbidity and mortality arising from irreversible joint destruction and overwhelming sepsis. The purpose of this prospective study is to present epidemiological, clinical and laboratory findings in adult patients with septic arthritis. Adult patients treated for septic arthritis at the Department of Infectious Diseases, University Medical Centre Ljubljana, Slovenia, from January 2012 to December 2014, qualified for the present report. The following data were analyzed: age, sex, underlying diseases, previous joint procedure, microbiological diagnostic examinations, causative agents, complications and therapy. During the study period of three years 94 episodes of septic arthritis were diagnosed. There were 49 (52.1%) females and 45 (47.9%) males, aged 64.5 (18 to 97) years. At the first visit elevated concentration of C-reactive protein was found in 93 (98.9%) patients. The most common affected joint was knee (48.9%), followed by shoulder (20.2%), wrist (12.8%), ankle (7.4%) and others. In 8 (8.5%) patients more than one joint was affected. Risk factors were found in 63 (67%) of study patients. The underlying joint disease (e.g. osteoarthritis, rheumatoid arthritis, gout) was found in 50.8% patients, following by malignancy and immunosuppressive therapy in 28.6%, diabetes mellitus in 14.9%, recent trauma in 12.8%, and prior joint procedure in 9.6% patients. In 65/94 (69.1%) patients the causative pathogen was demonstrated by blood culture in 35.6%, by synovial fluid culture in 48.8%, and by both methods in 13.8% patients. In patients with proven aetiology Staphylococcus aureus was the most frequent (44.6%) isolated pathogen (only one methicillin resistant), followed by gram-negative bacteria in 30.8%, and Streptococcus spp. in 23.1% patients. In 4/65 (6.2%) patients more than one pathogen was isolated. The patients were treated with antibiotics according to isolated pathogen. In 17 (70.8%) out of 24 patients with complications synovectomia was performed, and adjacent osteomyelitis was found in 9 (37.5%) patients. Our results show that the foremost risk factor in adult patients with septic arthritis is pre-existing joint disease, knee is the principal target of infection, and the most common isolated pathogen is S. aureus. It was established that prompt recognition, early appropriate antimicrobial and surgical treatment in these patients are critical to ensuring a good prognosis

Non-tuberculous mycobacterial (NTM) infection of the musculoskeletal tissue is a rare disease. An early and accurate diagnosis is often difficult because of the indolent clinical course and difficulty of isolating pathogens. Our goal was to determine the clinical features of musculoskeletal NTM infection and to present the treatment outcomes. A total of 29 patients (nine females, 20 males between 34 and 85 years old, mean age 61.7 years; 34 to 85) with NTM infection of the musculoskeletal system between 1998 to 2011 were identified and their treatment retrospectively analysed. Microbiological studies demonstrated NTM in 29 patients: the isolates were Mycobacterium intracellulare in six patients, M. fortuitum in three, M. abscessus in two and M. marinum in one. In the remaining patients we failed to identify the species. The involved sites were the hand/wrist in nine patients the knee in five patients, spine in four patients, foot in two patients, elbow in two patients, shoulder in one, ankle in two patients, leg in three patients and multiple in one patient. The mean interval between the appearance of symptoms and diagnosis was 20.8 months (1.5 to 180). All patients underwent surgical treatment and antimicrobial medication according to our protocol for chronic musculoskeletal infection: 20 patients had NTM-specific medication and nine had conventional antimicrobial therapy. At the final follow-up 22 patients were cured, three failed to respond to treatment and four were lost to follow-up. Identifying these diseases due the initial non-specific presentation can be difficult. Treatment consists of surgical intervention and adequate antimicrobial therapy, which can result in satisfactory outcomes.

Cite this article: Bone Joint J 2014;96-B:1561–5.