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Abstracts Posters
P01
Vancogenx pre-mixed, antibiotic cement in revision total knee replacement
Ammar Abbas 1, Rhidian Morgan-Jones2
1
Cardiff And Vale University Health Board, Cardiff, United Kingdom
2
University Hospital Of Llandough, Cardiff, United Kingdom
Introduction: Infected TKR remains a difficult problem for
both patient and surgeon. The use of antibiotic loaded cement has been a mainstay of treatment for many years. The
arrival of pre-mixed dual antibiotics is seen as a significant
advance and we discuss the rationale for its use.
Patients and Methods: Between March 2011 and March
2013, we used pre-mixed Vancomycin and Gentamicin Vancogenx cement (Orthodynamics, Gloucestershire, UK) during the treatment of 24 consecutive patients with infected
TKR. Of this cohort, 16 had one-stage revision, 6 two-stage
revision and 2 cement arthrodesis. 65% of cases were infected re-revisions.
Results: At a minimum 12 months (range 12-36) review,
only one infection has recurred. The failed case was a multi
revised, poly-microbial infection and has since undergone a
further revision. Cement handling was satisfactory and no
adverse events were recorded.
Conclusion: Vancogenx pre-mixed antibiotic cement can
be used successfully, as part of the management strategy
for treating infected revision TKR.
P02
114
Influence of poly-N-acetylglucosamine in the extracellular matrix on N-chlorotaurine
mediated killing of staphylococcus epidermidis
Débora Cristina Coraça-Huber, Christoph G Ammann, Manfred Fille, Johann Hausdorfer, Michael Nogler, Markus Nagl
Innsbruck Medical University, Innsbruck, Austria
Aim: N–chlorotaurine (NCT) has recently been shown to have
bactericidal activity against bacterial biofilm on metal discs.
In a biofilm, Staphylococcus epidermidis polymerizes polyN-acetylglucosamine (PNAG) to form an extracellular matrix
(ECM). Pseudomonas aeruginosa does not express this PNAG
and have been shown to be highly susceptible to NCT.
Methods: We here compare the action of NCT on S. epidermidis 1457, a PNAG positive strain (SE1457) and S. epidermidis
1457-M10 an isogenic PNAG negative mutant (SE1457 M10).
Results: NCT mediated killing was more effective and
quicker on the PNAG negative strain SE1457 M10. Old bio-
films were generally more susceptible compared to freshly
formed biofilms.
Conclusions: The differences in NCT mediated killing might
not be direct effects since NCT did not react with the monomeric N-Acetylglucosamine but might be explained by
denser growth in the PNAG containing biofilm produced by
the wild type strain, which results in delayed penetration of
NCT. The higher susceptibility of older biofilms to NCT mediated killing could be explained by more pronounced 3D
architecture and subsequent larger surface area for interactions with NCT.
P03
In vitro study of new combinations for local antibiotic therapy with calcium sulphate – slow
release of ceftriaxone offers new treatment options
Peter Wahl 1, Karoline Rönn2, Marc Bohner3, Laurent Arthur Decosterd4, Sandrine Festa5, Emanuel Gautier5
1
Cantonal Hospital Winterthur, Winterthur, Switzerland
2
Hirslanden Klinik Zürich, Zürich, Switzerland
3
Rms Foundation, Bettlach, Switzerland
4
University Hospital Centre Lausanne, Lausanne, Switzerland
5
Hfr Fribourg - Cantonal Hospital, Fribourg, Switzerland
33rd Annual Meeting of the European Bone & Joint Infection Society
Abstracts Posters
Aim: In the treatment of bone and joint infections, antibiotics are commonly applied locally in order to increase local concentrations with a reduced risk of systemic toxicity.
The carrier material also helps managing dead space left by
debridement. However, a larger choice of antibiotics, optimized release kinetics, and resorbable materials would offer
new possibilities answering the complexity of musculoskeletal infections. Calcium sulphate (CaSO4) is compatible with
many antibiotics, is resorbable, and has a dissolution time
that only slightly exceeds the usually recommended duration of systemic antibiotic treatments. This in vitro study
evaluates compatibility, release kinetics and antibacterial activity of various new combinations of antibiotics with
CaSO4 as carrier material.
Materials: Pellets were manufactured using custom made
CaSO4 alpha-hemihydrate, added with 4 % w/w of antibiotic powder and demineralised water. Excess water was removed by drying in a dessicator. Elution of the antibiotics
from these pellets was examined at various time points for
up to 6 weeks at 37 °C, once in phosphate-buffered saline
(PBS) solution, and once in bovine plasma. The elution fluid
was exchanged daily. Antibiotic concentration was mea-
sured batch-wise by liquid chromatography with tandem
mass spectrometry from samples stored at -80 °C. Antimicrobial activity was double-checked with a classical agar diffusion test, using either S. aureus ATCC 25922 or E. coli ATCC
35218 depending on the antibiotic examined.
Results: While piperacillin-tazobactam, ceftazidime, cefepime, and meropenem showed fast reduction of concentration and activity, flucloxacillin and cefuroxime remained
present in relevant concentrations for 4 weeks. Ciprofloxacin, levofloxacin and clindamycin even for 6 weeks, but at
the beginning partly in cell toxic concentrations. The profile
of ceftriaxone showed a release with only a small reduction
of concentration and activity from 130 to 75 mg/l. Elution
profiles from PBS and plasma were comparable
Conclusion: CaSO4 as a resorbable carrier provides new possibilities in the local treatment of bone and joint infections.
Ceftriaxone appears to be of particular interest in combination with this carrier material. Not only does it persist at clinically promising concentrations, but also it appears to have
a depot-like slow release from calcium sulphate, with only a
small reduction in activity and concentration over 6 weeks.
P04
The prevention of bacterial colonisation and biofilm formation using antibiotic-loaded
synthetic calcium sulfate beads
Robert Howlin 1, Stephen McConoughey2, Michael Brayford3, Jeremy Webb4, John Cooper3, Sean Aiken3, Jason Calhoun2,Paul
Stoodley2
1
University Of Southampton And University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
2
The Ohio State University, Ohio, United States
3
Biocomposites Ltd, Keele, United Kingdom
4
University Of Southampton, Southampton, United Kingdom
Aim: Localised infections associated with prosthetic implants are often the result of bacterial adhesion and subsequent biofilm formation on the surface of the biomaterial
and the periprosthetic tissue. Biofilms become highly tolerant to antibiotics and resistant to host clearance thus preventing successful tissue integration. It is thus crucial to kill
bacteria at the surface of the implant and in the immediate
vicinity before a biofilm can become established. Absorbable cements have potential for improved elution of a wide
range of antibiotics and complete biodegradation ensures
that they do not themselves become a foci for infection. This
study evaluated the in vitro antimicrobial and anti-biofilm
efficacy of antibiotic-loaded synthetic calcium sulphate (CS)
with pathogens commonly associated with periprosthetic
infection (PI).
Methods: S. epidermidis, P. aeruginosa, methicillin sensitive and resistant S. aureus (MSSA & MRSA), K. pneumonia,
A. baumannii and P. acnes strains were characterised based
on their resistance profiles to vancomycin, tobramycin and
a combination treatment against planktonic and biofilm
bacteria. Synthetic CS beads loaded with antibiotics were
assessed for their ability to eradicate planktonic bacteria.
The ability of antibiotic-loaded CS beads to prevent biofilm
formation in the presence of daily bacterial challenges was
evaluated over 14 days using viable cell counts, confocal
and scanning electron microscopy. The ability of CS beads
to kill preformed biofilms over 72 hours was studied.
Results: A 100 to 1000 fold increased tolerance to antibiotics was displayed by biofilm bacteria when compared to
planktonic counterparts. Antibiotic-loaded CS beads killed
planktonic cultures of 106 CFU/ml, prevented bacterial
colonisation over multiple days and significantly (P<0.05)
reduced biofilm formation over a period of 7 and 14 successive daily bacterial challenges. A complete kill of established
P. aeruginosa and MSSA biofilms was achieved. Established
MRSA and S. epidermidis biofilms were reduced but proved
more difficult to eradicate. In all strains, apart from MSSA,
the log reduction by the combination treatment against
day 7 or 14 biofilms was significantly greater than the sum
of the vancomycin and tobramycin reductions alone, suggesting a synergistic effect.
Conclusions: Synthetic antibiotic-loaded CS beads have potential to reduce or eliminate biofilm formation on periprosthetic tissue and prosthesis material, and thus reduce rates
September 11-13, 2014 - Utrecht - The Netherlands
115
Abstracts Posters
of periprosthetic infection. These data further demonstrate
the difficulty in clearing established biofilms and the need
for early preventative measures to reduce the risk of PI.
Acknowledgments
This work was funded by Biocomposites Ltd.
P05
Combined negative wound pressure therapy and instillation for killing methicillin-resistant
staphylococcus aureus biofilms on titanium surfaces in-vitro
Garth James 1, Laura Boegli 1, Chris Lessing2, Steve Fisher 1, Amanda Durch 1, Christopher Carroll2
1
Montana State University, Bozeman, United States
2
Kinetic Concepts Inc., San Antonio, United States
116
Aim: In this study periodic solution instillation with a defined dwell time followed by negative pressure wound
therapy* (NPWTi-d) over a 24 hour period was compared to
a one-time solution treatment followed by 24 hours of continuous negative pressure wound therapy (NPWT) for killing
methicillin-resistant Staphylococcus aureus (MRSA) biofilms
using an in-vitro model.
Methods: MRSA (ATCC 700789) biofilms were grown on titanium slides in a drip-flow reactor for 2 days. The slides
were placed on agar slabs and covered with instillation
foam dressings. The single-application plus NPWT groups
(SA+NPWT) received one treatment with different solutions
(saline, 0.125% Dakin’s solution, or 0.1% polyhexanide plus
0.1% betaine) for 20 minutes followed by continuous NPWT
for 24 hours. For each solution tested, an NPWTi-d group was
treated repeatedly over 24 hours using a 20 minute dwell
followed by NPWT for 3.5 hours. After the solution dwell
and during application of negative pressure at 125 mmHg,
simulated wound exudate was supplied to the biofilms of
both groups at a flow rate of 5 ml/hour. Surviving bacteria
were enumerated by plate count and used to calculate log
reductions relative to an untreated biofilm control. Mean log
reductions (MLR) ± standard deviation were calculated from
at least three repeat experiments and compared by ANOVA.
Results: For saline treatment, MLRs were negligible for both
NPWTi-d ( 0.33±0.48) and SA+NPWT ( 0.28±0.27). Dakin’s solution produced MLRs of 2.15±0.52 and 0.75±0.75, for NPWTid and SA+NPWT, respectively. The polyhexanide/betaine solution had MLRs of 5.53±0.75 and 0.35±0.32, for NPWTi-d and
SA-NPWT, respectively. For both Dakin’s and polyhexanide/
betaine, MLRs for NPWTi-d were significantly greater than
for SA+NPWT (p=0.0398 and p<0.0001, respectively). For
both NPWTi-d and SA-NPWT treatments, MLRs for Dakin’s
solution were significantly greater than saline, p=0.0051 and
p=0.0305 respectively. For NPWTi-d treatments, the MLR for
polyhexanide/betaine was significantly greater than both
Dakin’s solution (p=0.0168) and saline (p=0.0027).
Conclusions: For 0.125% Dakin’s and 0.1% polyhexanide +
0.1% betaine, NWPTi-d was superior to SA+NPWT for killing
MRSA biofilms. For SA-NPWT, Dakin’s solution was the most
effective, while for NPWTi-d the polyhexanide/betaine solution was the most effective.
*V.A.C. VeraFlo™ Therapy, KCI, San Antonio, TX, USA
P06
WITHDRAWN
P07
Candida arthritis: report of two cases
Stanka Lotrič-Furlan, Petra Bogovič, Jelka Meglič-Volkar, Tereza Rojko
Department Of Infectious Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
Aim: Although uncommon, fungal arthritis causes major
morbidity and may be associated with serious complications. The aim of the present study was to evaluate the
frequency of septic arthritis caused by Candida spp at the
Department of Infectious Diseases in Ljubljana and describe
the clinical and laboratory characteristics, complications
and outcome of the disease.
Materials and Methods: Case records of patients with septic arthritis treated in our institution, during the prospective
study in the period 2012-2013 were reviewed. The following
33rd Annual Meeting of the European Bone & Joint Infection Society
Abstracts Posters
data were recorded: age, sex, underlying diseases, clinical
features, causative agents, results of the diagnostic examinations, complications and outcome of the disease.
Results: During the study period of two years 2 (3.8%) out
of 53 patients with typical features of septic arthritis were
diagnosed with fungal arthritis. There was one female and
one male, aged 72 and 60 years, respectively.
A 60-year-old man with rheumatoid arthritis, who had
been treated with infliximab and prednisolone, presented
with sternoclavicular joint arthritis due to Candida albicans,
which was isolated from aspirated joint fluid. The patient
received fluconazole and surgical treatment consisted of
debridement and resection of the affected bone.
The other patient was a 72 year old woman without the
predisposing diseases complaining of a right shoulder pain.
She had undergone injection of analgesic and corticosteroid one month before for suspected rupture of rotator cuff.
Candida parapsilosis was isolated from joint fluid. The right
shoulder MRI and the findings of the body bone scan were
suggestive for bursitis and osteomyelitis of the proximal
part of the humerus. She was treated with fluconazole and
intensive debridement. Both patients were asymptomatic
without infection recurrence at the final follow up.
Conclusions: Our study of septic arthritis has demonstrated
that the predominant causative agent of septic arthritis
was Staphylococcus aureus, but fungal arthritis may also be
considered in rheumatoid arthritis patients receiving antiTNF therapy and in patients after administration of intraarticular steroids. Treatment of candida joint infections is
not well established, but almost always includes antifungal
chemotherapy, with or without surgical debridement. In
conclusion, early diagnosis can decrease the morbidity and
mortality of this disease.
P08
WITHDRAWN
P09
Novel biomarkers to detect infection in orthopedic revision arthroplasy
Mathias Glehr 1, Gerald Gruber 1, Joerg Friesenbichler 1, Gerwin Bernhardt 1, Joanna Szkandera2, Alexander Avian3, Reinhard
Windhager4, Guenter Hofmann2, Florian Amerstorfer 1, Andreas Leithner 1
1
Medical University Of Graz, Department Of Orthopedic Surgery, Graz, Austria
2
Medical University Of Graz, Department Of Internal Medicine, Devision Of Oncology, Graz, Austria
3
Medical University Of Graz, Department Of Medical Information, Statistics And Documentation, Graz, Austria
4
Medical University Of Vienna, Department Of Orthopedic Surgery, Vienna, Austria
Background: In orthopedic revision surgery periprosthetic
joint infection (PJI) is one of the most challenging complications in orthopedic revision surgery. In the diagnostic
process for detecting PJI, one of the most important steps
remains the analysis of laboratory infection biomarkers.
Questions/purposes: We investigated the sensitivity and
specificity of the biomarkers procalcitonin (PCT), interleukin 6 (IL-6), and interferon α (IFN-α) as compared to conventional biomarkers (C-reactive protein [CRP], leukocyte level)
for PJI associated with orthopaedic revision surgery.
Methods: We prospectively included and analyzed 84 patients (124 orthopaedic revision operations). The blood parameters of interest were PCT, IL-6, IFN-α, leukocyte level,
and CRP. Samples were taken preoperatively and on the
first, third, and seventh postoperative days. The sensitivity
and specificity of these biomarkers were then calculated.
Results: Considering the preoperative values of 124 operations, PCT, IL-6, CRP, and leukocyte level correlated with PJI,
while IFN-α did not. A PCT cut-off level of 0.35 ng/mL revealed a sensitivity of 80% and a specificity of 37%. An IL-6
cut-off level of 2.55 pg/mL had a sensitivity of 92% and a
specificity of 59%.
Conclusions: In this study PCT and IL-6 were helpful for
detecting PJI in orthopedic revision surgery, although CRP
was generally the superior test. PCT and IL-6 may be considered adjuvant tests where the diagnosis of PJI is in doubt.
This study showed, besides conventional biomarkers such
as CRP and leukocyte level, PCT and IL-6 were helpful for
detecting infections associated with orthopaedic revision
surgery.
September 11-13, 2014 - Utrecht - The Netherlands
117
Abstracts Posters
P10
Prosthetic joint infection in latin america: improving microbiological diagnosis using
sonication
Mauro Salles, Maysa Yano, Cely Barreto, Maria Aparecida Murça, Stanley Nigro, Emerson Honda, Osmar Avanzi
Santa Casa De Sao Paulo School Of Medicine, Sao Paulo, Brazil
118
Currently, sonication of explanted orthopedic implants has
been considered an important technique which increases
the microbiological diagnosis of prosthetic joint infections
(PJI), but to our knowledge none Latin American studies
have addressed this issue. Objectives: We aim to investigate
if sonication fluid culture of explanted arthroplasties would
increase the microbial identifications of PJI when compared
with conventional cultures collected from peri-prosthetic
tissues. Phenotypic identification of pathogens and susceptibility tests was also performed. Methods In a single-center
prospective cohort study from August 2011 to July 2013, 86
prosthetic joints were evaluated, 63 hip, 21 knee, 1 elbow and
1 shoulder undergoing partial or total removal due any cause
were included. Diagnosis of PJI was based upon standard
criteria of infection as previously published. Minimal of two
samples from the peri-implant tissue were taken and sent under sterile conditions to the laboratory. The removal implants
were packed into sterilized solid polyethylene containers and
covered with Ringer’s solution, sonicated for 5 minutes at a
frequency of 40±2 kHz and power density 0.22±0.04 W/cm2,
followed by additional 30 seconds of vortexing. The sonicat-
ed fluid was cultured and the microorganisms isolated were
identified according to standard method. Statistical analysis
was performed using McNemar’s test for related proportions.
Results: Asseptic loosening was diagnosed in 30 patients
(34.8%) and PJI was diagnosed 56 patients (65.1%). Sensitivity,
specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) of peri-prosthetic tissue culture was 58.9
(95%CI: 0.45 a 0.7), 86.6% (95%CI: 0.7 a 0.94), 89.1% (95%CI:
0.45 a 0.7), 84.8 (95%CI: 0.7 a 0.94), respectively. Sensitivity,
specificity, PPV and NPV of sonication fluid culture was 91%
(95%CI: 0.8 a 0.96) (p <0,05), 90% (95%CI: 0.74 a 0.96), 94.3%
(95%CI: 0.8 a 0.96), 84.8% (95%CI: 0.75 a 0.96), respectively.
The most frequent organisms isolated from culture of sonication fluid were: coagulase-negative Staphylococcus (41.8%),
Staphylococcus aureus (13%), Enterococcus spp. (6.9%),
Proteus spp. (4.6%). Gram-negative bacilli was diagnosed in
26% and polimicrobial flora was detected in 18% of patients.
Conclusion: In our study, sonication technique improved the
microbiological diagnosis of prosthesis joint infections. Biofilm-forming pathogens such as coagulase-negative Staphylococcus were frequently identified on both methods.
P11
S. lugdunensis characteristics compared to S. epidermidis and S. aureus periprosthetic joint
infections
Julie Lourtet Hascoet, Aurelie Bouige, Marie Pierre Felice, Alain Bicart See, Gerard Giordano, Eric Bonnet
J. Ducuing Hospital, Toulouse, France
Aim: The objective of the study was to assess clinical and
bacteriological characteristics of Periprosthetic Joint Infections (PJI) due to S. lugdunensis (SL) and to compare them
to S. aureus (SA) and S. epidermidis (SE) PJI.
Methods: We conducted a retrospective multicentric study
in the same urban area. All cases of SL PJI were included
over a 2-year period. Same numbers of monomicrobial SA
and SE PJI were consecutively included. Clinical aspect, surgery type, bacteriological results, treatment and outcome
of patients were collected. Data were compared between
the 3 groups.
Results: We recorded 15 cases of staphylococcal PJI in each
group. PJI due to SL, SA and SE involved the knees in 8, 12,
and 8 cases, and the hips in 5, 3 and 7 cases respectively.
Fever was observed in 5 (33%) patients with SL PJI, 4 (27%)
with SA PJI, and none of the patients with SE PJI. The average
delay between surgery and infection was 7 months for SL
PJI, 12 for SA PJI and 29 for SE PJI.
Irrigation and debridement (ID) was performed in 9 (60%)
cases of SL PJI, 4 (26%) SA PJI, 2 (13%) SE PJI. One stage exchange was performed in 4 (26%) cases of SL PJI, 4 (26%) SA
PJI, and 9 (60%) SE PJI. Two stage revision was performed
in 2 (13%) cases of SL PJI, 7 (49%) SA PJI, and 4 (26%) SE PJI.
Four (27%) SL strains were resistant to penicillin G, 1 to rifampicin, none to methicillin or quinolones. Thirteen (87%)
SA strains were resistant to penicillin G, 2 (13%) to methicillin, 3 (20%) to quinolones, 1 to rifampicin. All SE strains were
resistant to penicillin G, 12 (80%) to methicillin, 10 (67%) to
quinolones and 1 to rifampicin. Eleven (73%) patients with
SL PJI, 13 (87%) with SA PJI and 9 (60%) with SE PJI were
treated with a levofloxacin-rifampicin combination. Mean
duration of treatment was 6.5 weeks in the 3 groups. Outcome was favourable in 13 (87%) SL PJI, 12 (80%) SA PJI, and
all cases of SE PJI.
Conclusion: SL is not a rare pathogen in PJI. SL PJI are quite
similar to SA PJI. They often occur early after surgery and
33rd Annual Meeting of the European Bone & Joint Infection Society
Abstracts Posters
therefore could be successfully treated by ID followed by
a 6-week antimicrobial treatment. Compared to SA and SE,
strains were more frequently susceptible to penicillin G,
methicillin and quinolones.
P12
WITHDRAWN
P13
WITHDRAWN
P14 (not presented)
Optimal sample set for microbial diagnosis of prosthetic joint infections
Lone Heimann Larsen1, Yijuan Xu2,Vesal Khalid3, Henrik C Schønheyder4, Trine Rolighed Thomsen5
Department Of Clinical Microbiology, Aalborg University Hospital, Center For Microbial Communities, Department Of
Biotechnology, Chemistry And Environmental Engineering, Aalborg University, Aalborg, Denmark
2
Center For Microbial Communities, Department Of Biotechnology, Chemistry And Environmental Engineering, Aalborg
University, Aalborg, Denmark
3
Orthopaedic Surgical Research Unit, Aalborg University Hospital, Aalborg, Denmark
4
Department Of Clinical Microbiology, Aalborg University Hospital, Department Of Clinical Medicine, Aalborg University,
Aalborg, Denmark
5
Center For Microbial Communities, Department Of Biotechnology, Chemistry And Environmental Engineering, Aalborg
University, Danish Technological Instutute, Medical Biotechnology, Aalborg, Aarhus, Denmark
1
Aim: Many studies have been published lately with suggestions for improved microbial diagnostic of prosthetic joint
infections (PJI). However, international guidelines are still
lacking exact recommendations for the specific types of
specimes needed for optimal diagnosis. It is generally accepted that the prosthetic component itself (PC) and tissue
biopsies (TB, min. 5) play a crucial role, but joint fluid (JF),
prosthetic swabs in-situ (PS), and bone biopsies (BB) have
also been studied. We here recommend an optimal sample
set for diagnosis of PJI based on a 2-year prospective study
with systematic sampling from patients with prosthesis-related problems in the hip or knee.
Methods: Three samples of JF were obtained by joint puncture and 18 samples during revision surgery. Specimens
were cultured within 2-24h and incubated for 14 days. Corresponding specimens for culture-independent (16S rDNA
sequencing and FISH) methods were stored at -80°C until
analysed batchwise.
Results: JF or JF plus TB, BB, PC, and PS were collected during 164 procedures (‘cases’) in 131 patients with an overall
sample completeness of ~90%. In 46 cases PJI was suspected and revision was carried out. 37 were culture positive and 9 cases were culture negative; two culture negative case was positive by 16S rDNA sequencing of a parallel
molecular sample. TB, PC, and JF contributed to a positive
result in 95%, 97%, and 91 % of the cases, whereas PS and
BB contributed in 43% and 44%, respectively.
Conclusions: The optimal sample set for PJI consists of TB,
JF and PC.
PRIS is supported by The Danish Council for Technology and
Innovation.
Contribution to positive results by case.
A: 31 cases had complete sets of TB, PC,
and JF; (*) one unmatched positive was
confirmed by BB and PS.
B: In 23 cases all sample types were obtained; neither BB nor PS contributed
with additional inform.
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119
Abstracts Posters
P15
Preoperative imaging with 18f-fdg-pet/ct, combined 111in/99tc-nanocoll-spect/ct, and
99tc-hdp in painful hip and knee prostheses: preliminary results from prospective study
Ramune Aleksyniene 1, Majbritt Frost 1, Henrik Christian Bertelsen 1, Victor Iyer 1, Magdalene Kubik 1, Vesal Khalid2, Henrik Carl
Schønheyder3
1
Nuclear Medicine Department, Aalborg University Hospital, Aalborg, Denmark
2
Orthopaedic Surgery, Aalborg University Hospital, Aalborg, Denmark
3
Microbiology Department, Aalborg University Hospital, Aalborg, Denmark
120
Aim: The aim of the study was to evaluate the tracer uptake
in patients with a painful knee or hip prosthesis in extended
diagnostic hybrid imaging (99Tc-HDP SPECT/CT, combined
111In-leukocyte/99Tc-Nanocoll SPECT/CT, and 18F-FDG
PET/CT) and to compare imaging results with the intraoperative findings and culture reports.
Methods: The study is a part of the Danish Project “Prosthetic –Related Infection and Pain” (Danish acronym PRIS) and is
approved by the local science ethics committee. Fifty five
patients (26 women and 29 men, mean age 64 years) with
a chronic painful knee (n=29) or hip (n=26) prosthesis had
a clinical examination, standard radiographs, and extended
imaging with 99Tc – HDP SPECT/CT, 111In-labeled WBC
combined with 99Tc-nannocol bone marrow SPECT/CT, and
18F-FDG PET/CT. The combined imaging report comprising
all three hybrid imaging modalities in conjunction with the
clinical data were evaluated at MDT conferences and guided
the patient management. The final diagnosis of infection or
loosening was based on intraoperative findings, culture of
joint fluid and intraoperative samples (n=23) or clinical follow-up (n=29); 3 patients refused following investigations.
Results: 21 patient (38%) was scheduled for clinical followup due to negative all three scans in 7 patients, and positive
bone scan only in 14 patients. In 23 patients (42%) the final diagnosis was obtained by surgical findings and/or microbiology. Bone scan showed increased uptake in all cases, combined
111In-labeled WBC / 99Tc-nannocol bone marrow SPECT/CT
imaging and 18F-FDG PET/CT revealed increased uptake in
bone-prosthesis interface and/or in surrounding soft tissue
in 100% when infected in 13 patients, but increased uptake
on PET/CT scans was also reported in the aseptic loosening
and/or inflammation in 9 cases (40%). 7 patients with positive scans did not go to surgery but were followed-up due to
other reasons (severe comorbidity, mild symptoms).
Conclusion: Extended hybrid imaging combines functional
and anatomical imaging and enables multiplanar reconstruction and manipulation of imaging data, which can be used to
guide management. The 99Tc- SPECT/CT cannot distinguish
between aseptic loosening and periprosthetic infection, but
it can be clinically useful especially when negative. Additional CT may detect anatomical complications (periprosthetic
lucency, heterotopic ossification, periprosthetic fractures,
soft tissue changes) and bone scan SPECT/CT can be a gatekeeper for further functional imaging. Reliable differentiation
between septic and aseptic periprosthetic complications was
not possible using 18F-FDG PET/CT, but combined 111Inlabeled WBC / 99Tc-nannocol bone marrow SPECT/CT is a
promising tool for the evaluation periprosthetic infections.
P16
Synovial fluid procalcitonin and the diagnosis of potential implant related joint infections
Kordo Saeed 1, Matthew Dryden2
1
Hampshire Hospitals Nhs Foundation Trust, Southampton University Medical School, Winchester, United Kingdom
2
Hampshire Hospitals Nhs Foundation Trust, Hampshire, United Kingdom
Aim: Ambiguous diagnosis in prosthetic joint infection (PJI)
cases creates significant psychological stress for patients and
surgeons. Any test that can assist in the diagnosis of PJI would
be of major value to provide early efficacious treatment.
During systemic bacterial infection Procalcitonin (PCT), a
precursor of the hormone calcitonin, is secreted by almost
every single organ and can easily be detected in the sera.
However, serum PCT lacks sensitivity in the diagnosis of PJI,
particularly in localised infections when there are no systemic features [1-4]. Our aims were to highlight that measurement of synovial PCT could provide an aid in the diagnosis of PJI and to encourage collaborative future studies.
Methodology: Using standard quantitative enzyme immuno assay*, synovial PCT levels were measured, retrospectively, in predefined patients with PJIs and non-infected
(aseptic) loosening.
Results: Synovial PCT was measured in 17 cases with either
predefined PJI or aseptic loosening (Figure-1). Median synovial PCT in the PJI group was 3.15 µg/L vs. 0.05µg/L in the
aseptic loosening.
Conclusion: In this small cohort, we have demonstrated that
synovial PCT can be found in quantifiable concentrations
with a trend of higher values in PJI vs. aseptic loosening
cases. Highest synovial PCT levels were seen in Staphylococ-
33rd Annual Meeting of the European Bone & Joint Infection Society
Abstracts Posters
cus aureus infections regardless of presence of concomitant
bacteraemia. The lowest value was in a case of CoagulaseNegative Staphylococcus (CoNS) PJI. Synovial PCT warrants
further and larger studies to confirm its usefulness in assisting clinicians in the diagnosis or exclusion of potential PJI.
PJI cases and organisms
Case 1
Staphylococcus aureus
Case 2
S. aureus
Case 3
S. aureus
Case 4
S. aureus
Case 5
S. aureus
Case 6 Eneterococcus
Escherichia
Case 7
coli
Case 8
Coagulase
negative Staphylococcus
1. So¨derquist B et al. Scand J Infect Dis 1998;30:591–6.
2. Bottner F et al. J Bone Joint Surg Br. 2007;89:94–9.
3. Worthington T et al. Br J Biomed Sci. 2010;67:71–6.
4. Randau T et al. Eur Cells Mater. 2011;21:36.
* BRAHMS UK Limited
Synovial PCT µg/L
Aseptic loosening cases
Synovial PCT µg/L
18.33
Case 1
0.05
14.51
7.13
2.71
1.87
3.54
Case 2
Case 3
Case 4
Case 5
Case 6
0.2
0.06
0.05
0.05
0.05
1.9
Case 7
0.06
0.05
Case 8
0.18
Case 9
0.08
Synovial PCT values in PJI and aseptic loosening cases in µg/L
P17
WITHDRAWN
121
P18
Rate of knee prosthetic joint infection and their treatment: a single centre study
Stefania Marocco 1, Andrea Angheben 1, Fabrizio Cortese2, Gianluca Piovan2, Giuseppe Niccoli2, Chiara Savio3, Davide Brunelli4,
Claudio Zorzi2
1
Centre For Tropical Disease Sacro Cuore-Don Calabria Hospital Negrar, Verona, Italy
2
Orthopedic And Traumatology Department Sacro Cuore-Don Calabria Hospital Negrar, Verona, Italy
3
Service Of Microbiology Sacro Cuore-Don Calabria Hospital Negrar, Verona, Italy
4
Health Care Department Sacro Cuore-Don Calabria Hospital Negrar, Verona, Italy
Aim: The growing number of knee joint arthroplasty procedures recorded in the last decades contributed to an increasing number of related infections and the need of an
integrated management between surgeon and infectious
disease specialist. Aim of our work was to determine retrospectively the rate of knee prosthetic infections (KPI) and
describe management of our infected patients through an
integrated protocol.
Methods: patient files have been retrospectively reviewed
from 01/01/2011 to 31/12/2012, eventually recontacting patients by phone contact in case of lacking data, in a
1 (group B) and 2 years (group A) follow-up period. Case
definition of a knee prosthetic joint infection was: clinical
picture (pain/inflammation/increased CRP) + either positive
labelled-leukocytes scintigraphy (LLS) or microbiological
proven infection.
Results: in a two years period 1001 knee prosthesis have
been placed at our Hospital; follow-up of 12-24 months
was available for 597 (group B ) and 504 cases (group A),
respectively. A rate of KPI was 1.19% for group A and 0.33%
for group B. The 8 KPI were treated through an integrated
institutional protocol:
- 1st choice: infected prosthetic joint removal, spacer with
antibiotics implant, 8-12 weeks of microbiologically-driven
antibiotic treatment, at least one month wash-out with inflammation (CRP) monitoring, prosthesis replacement if
CRP normal and LLS negative.;
- 2nd choice: microbiologically-driven antibiotic treatment
with chronic or cyclic antibiotic administration in case of
clinical/surgical contraindications or patient refuse.
Conclusions: in our Centre after at least one year follow-up,
the rate of post knee-arthroplasty infection is low. In case
of infectious complications, an integrated management by
surgeon and infectious disease specialist has been set up
by an institutional protocol. Further studies are planned to
evaluate the efficacy of that protocol and to monitor the
rate of prosthetic joint infections.
September 11-13, 2014 - Utrecht - The Netherlands
Abstracts Posters
P19
Role of sonication in the microbiological diagnosis of prosthetic-joint infections
Daniela Talapan 1, Vlad Predescu2, Raluca Mihailescu 1, Olga Dorobat 1, Alexandru Rafila3, Rodica Marinescu4, Olivera
Lupescu4,Florian Purghel5, Marius Niculescu6, Razvan Ene7, Alexandru Hera8, Daniela Munteanu9, Catalin Carstoiu 10, Victoria
Arama 11, Adrian Streinu-Cercel 11
1
National Institute Of Infectious Diseases ‘Prof. Dr. Matei Bals’, Bucharest, Romania
2
Emergency Clinical Hospital ‘Sf. Pantelimon’, Department Of Orthopedics And Traumatology; University Of Medicine And
Pharmacy ‘Carol Davila’, Bucharest, Romania
3
National Institute Of Infectious Diseases ‘Prof. Dr. Matei Bals’ ; University Of Medicine And Pharmacy ‘Carol Davila’, Bucharest,
Romania
4
Clinical Hospital Colentina, Department Of Orthopedics And Traumatology; University Of Medicine And Pharmacy ‘Carol
Davila’, Bucharest, Romania
5
Emergency Clinical Hospital “Prof. Dr. Bagdazar-Arseni”, Department Of Orthopedics And Traumatology; University Of Medicine
And Pharmacy ‘Carol Davila’, Bucharest, Romania
6
Clinical Hospital Colentina, Department Of Orthopedics And Traumatology, Bucharest, Romania
7
Emergency University Hospital, Department Of Orthopedics And Traumatology, Bucharest, Romania
8
Emergency Clinical Hospital ‘Prof. Dr. Bagdazar-Arseni’, Department Of Orthopedics And Traumatology, Bucharest, Romania
9
National Institute Of Infectious Diseases ‘Prof. Dr. Matei Bals’, Bucharest, Romania
10
Emergency University Hospital, Department Of Orthopedics And Traumatology; University Of Medicine And Pharmacy ‘Carol
Davila’, Bucharest, Romania
11
National Institute Of Infectious Diseases ‘Prof. Dr. Matei Bals’ ; University Of Medicine And Pharmacy ‘Carol Davila’, Bucharest,
Romania
122
Aim: Although endorsed by international guidelines of Infectious Diseases, sonication is not yet worldwide accessible. In Romania, sonication of the medical implants was first
introduced in 2012. We present the microbiological profile
of the orthopedic implants sonicated in this country.
Methods: Sonication was performed on BactoSonic® ultrasonic bath (Bandelin, Germany). Containers were vortexed
and sonicated at 40 kHz for 1 minute. The sonicate, containing dislodged microorganisms from the implant, were
cultured on blood agar, chocolate agar, CLED agar and thioglycollate broth. Aerob cultures were incubated for 5 days,
while anaerob cultures - 10 days. Vitek® automated system
(BioMérieux, France) was used for identification and susceptibility tests.
Results: Among the 53 sonicated medical implants in 18
months, 36 were orthopedic implants: 16 hip prothesis,
12 knee prothesis and 8 fracture fixation devices. Monomicrobial infections were revealed in 19 cases: meticillin - resistant staphylococci (Staphylococcus aureus –n=5,
Staphylococcus warneri –n=1, Staphylococcus epidermidis
–n=4), meticillin - susceptible Staphylococcus aureus (n=2),
Streptococcus agalactiae (n=1), Burkholderia cepacia (n=2),
Serratia marcescens (n=1), Ochrobactrum antropi (n=1),
Pseudomonas aeruginosa (n=1), Parvimonas micra (n=1).
Polymicrobial infections were found in 6 cases, as follows:
meticillin - resistant Staphylococcus aureus and Corynebacterium striatum (n=1), meticillin - susceptible Staphylococcus aureus and streptococcus pyogenes (n=1), meticillin
- resistant coagulase-negative staphylococcus and Enterococcus faecalis (n=1), Staphylococcus aureus and Burkholderia cepacia (n=2); Pseudomonas aeruginosa, Klebsiella
pneumoniae ESBL+ and Enterococcus faecalis (n=1). Seven
control implants were indeed culture-negative. A correlation between cultures and clinical findings was found in
89% of cases (32/36). Pseudomonas aeruginosa and two
Staphylococcus aureus strains were isolated only after sonication and not in peri-prosthetic or pre-operative synovial
fluid cultures.
Conclusions: Sonication optimizes microbiological diagnosis
of implant-associated infections, even when the infection is
polymicrobial. Sonication also revealed nosocomial infections which needed further epidemiological measures. In a
country where prevalence of multi-resistant germs is high,
targeting antibiotics exclusively towards specific etiology,
as revealed by means of sonication, prevents from the emergence of new resistant strains. A multidisciplinary approach
(Orthopedics, Microbiology, Infectious Diseases) is essential
for the management of implant-asociated infections.
33rd Annual Meeting of the European Bone & Joint Infection Society
Abstracts Posters
P20
An unusual case of doubtful and unpredictable intraarticular infection
Matteo Carlo Ferrari, Federico Della Rocca, Alessandro Eusebio, Emanuele Caldarella, Gianluca Galimberti, Guido Grappiolo
Humanitas Research Hospital, Rozzano (Milan), Italy
Aim: Almost any bacteria can induce prosthetic joint infections. We describe an unusual case of Acinetobacter baumannii presence in hip joint pulvinar in a patient submitted
to first implant of total hip replacement.
Methods: A 47 years old male, known for previous contralateral hip replacement (2012), heavy smoker, overweight,
with borderline arterial hypertension, was admitted for first
left hip replacement. Pre-operative analysis were all in normal range. Waiting for surgery, the patient was submitted
to intra-articular jaluronic acid infiltrations. During surgery,
an unusual pseudocystic material was found in acetabular
pulvinar and removed with leakage of similar-purulent material, which was sent to pathology and to microbiology examination. The orthopedic surgeon, after abundant lavage,
decided to implant a total hip prosthesis.
Results: Pathology result shows: nodular formation of necrotic-colliquative tissue with inflammation and foreignbody giant cell and calcify fragments. Microbiology result
unpredictably revealed the presence of a MDR strain of
Acinetobacter baumannii, sensible only to colistin. The
postoperative clinical conditions and biochemical results
were completely normal, without any fever, normal WBC
count, CRP was quickly back to normal range (2.7 mg/dl after 7 days and 0.6 mg/dl after 12 days; n.v. <1), the surgical
wound was in perfect condition, and therefore we decided
not to consider the patient as infected.
Conclusions: This is the first case to our knowledge of intraarticular localization of a very harmful bacteria without the
presence of prosthetic implanted material. The patient will
be clinically and biochemically strictly monitorised in the
next months to exclude an infection reactivation inducing
prosthetic joint mobilization. Intra-articular jaluronic acid
infiltrations are not completely safe procedures and must
be performed only in selected cases following the best possible aseptic conditions. Before performing them , the patient must be appraised about the possible adverse effects
connected with these invasive procedures.
123
P21
The effectiveness of daptomycin and teicoplanin in the treatment of osteomyelitis
Ömer Karaşahin, Murat Dizbay, Özlem Güzel Tunçcan, Yeşim Yıldız, Kenan Hızel
Gaziuniversity Faculty Of Medicine, Ankara, Turkey
Aim:This study aims to investigate the clinical outcomes of
daptomycin and teicoplanin treatments in osteomyelitis.
Method: Patients who received teicoplanin and daptomycin treatments against osteomyelitis between April 2012
and April 2013 were analyzed retrospectively. The diagnosis
of osteomyelitis was done with MRG or bone scintigraphy.
Bone culture was taken whenever possible. Patients were
classified as “cured”, “improved” or “non-responded” according to the outcome of treatment. The follow-ups of the patients between 6th and 12th months were evaluated from
the patient records. The “cured” and “improved” patients
were accepted as success. Data was interpreted with descriptive statistics.
Results: Sixty patients were followed with osteomyelitis
during the study period. Of the patients, 37 (61,7%) were
female and 23 (38,3%) male. The mean age was 62,32±14,21
years mean treatment duration was 20,22±28,79 days. Fifty
percent of the patients was treated with teicoplanin and the
rest was treated with daptomycin. Osteomyelitis was existing at more than one location in 54 (90,0%) patients. The
most common anatomic location was patella/knee with a
frequency of 16,7%. Osteomyelitis was diagnosed with MRG
in 31 (51,7%) patients and bone scintigraphy in 29 (48,3%)
patients.
There was no significant difference regarding to the comorbid status of the patients between the daptomycin and
teicoplanin’s end-treatment and after-treatment success
(p>0,05). Success rates were calculated as 86.6% for both
daptomycin and teicoplanin. Daptomycin treatment was
found to be significantly more successful in patients who
had failure with other antibiotics in previous treatments
(p=0,001). In follow-ups, after-treatment success was found
significantly higher in patients who had surgery after medical therapy (p =0,001). Daptomycin treatment was discontinued due to elevation in CPK levels in 2 patients and skin
eruption in 1 patient.
Totally 46 microorganisms were isolated from the cultures
of 45 (75,0%) patients. The isolated microorganisms were
S. aureus (33.3%); CNS (31.6%); Pseudomonas spp. (3,3%);
Enterococcus spp. (5,1%); E. coli (1,7%); Streptococcus spp.
(%1,7). Culture results were negative in 21,7% of the patients. Significantly higher treatment success was achieved
in patients who received targeted therapy than the patients
received empirical therapy (p=0,009).
September 11-13, 2014 - Utrecht - The Netherlands
Abstracts Posters
Conclusion: It’s determined that daptomycin and teicoplanin treatments have higher clinical success frequency
in targeted osteomyelitis therapy and also have acceptable
side-effect profile. Daptomycin might have an advantage
in patients having previous osteomyelitis therapy. Applica-
tion of surgical procedures like debridement, removal of the
prosthesis, etc. is found to be associated with increased rate
of cure in osteomyelitis treatment.
P22
Chronic osteomyelitis treated with antibiotic-loaded biodegradable compounds
Daniel Haro Fernández, Raul Figa Barrios, Ivan Fuentes Lopez, Isidor Marchan Garcia, Alfredo Matamala Perez, Francesc Anglès
Crespo
University Hospital Of Mutua Terrassa, Terrassa, Barcelona, Spain
124
Aim: Treatment of chronic Osteomyelitis includes surgical
debridement and systemic antibiotic therapy.
Local antibiotic treatment by using antiobiotic delivery biodegradable vehicles (calcium sulphate and hydroxyapatite)
allows to achive higher and longer antibiotic concentrations locally. The purpose of our study was to analyze the
results of antibiotic- loaded biodegradable compounds for
chronic Osteomyelitis treatment.
Methods: Retrospective study of 59 cases in 58 patients
with chronic Osteomyelitis from May 2008 to December
2013 treated surgically at our Institution.
We identified 31 cases (30 patients) treated with resorbable
bone graft substitute and 28 cases treated with non- biodegradable compounds (antibiotic- loaded PMMA), that were
excluded from the study.
The clinical diagnosis was completed in all cases with additional laboratory tests (ESR and CRP), radiological imaging to quantify bone defects and microbiological cultures to
identify microorganisms.
In all cases biodegradable compounds (11 cases with Perossal® and 20 cases with Stimulan®) were employed adding local antibiotic depending microorganism (Gentamicin
and/ or Vancomycin) proceeding to fill the remaining cavity
after surgical debridement with an average volume of 10.4
cc (range, 2- 20 cc).
Results: The average age of these patients was 55 years
(range, 12- 87 years). Twenty- two patients were male and
8 were female. 24 cases (77,4%) with chronic lower limb
Osteomyelitis and 7 cases (22,6%) with chronic upper limb
Osteomyelitis.
The etiology of bone infection was: open fractures in 17 cases
(54,8%) and post- operative infections in 14 cases (45,2%).
The average evolution of Osteomyelitis was 110 months
(range, 1-360 months).
The isolated microorganisms were methicillin-sensible
Staphylococcus aureus in 12 cases, polimicrobian infections
in 7 cases, Staphylococcus epidermidis in 6 cases, Propionibacterium acnes in 3 cases, Enterobacter cloacae in 2 cases
and Escherichia coli in 1 case.
The mean follow- up after treatment was 24 months (range,
4- 71 months).
In 28 cases (90,3 %) it was performed in one-stage procedure and only in 3 cases (9,7%) in a two-stage.
Clinical and radiological remission was observed in 26 cases
(83,9%) at the end of follow- up, and no clinical or radiological remission in 5 cases (16,1%).
Four cases required fascio-cutaneous flap for reconstruction
of soft tissue defects.
Conclusions: We consider that antibiotic- loaded hydroxyapatite and calcium sulphate are safe and effective alternatives for local antibiotic delivery in the treatment of chronic
Osteomyelitis.
It allows delivering high antibiotic concentrations locally
without systemic involvement, a second operation for their
removal is not required and full fill residual dead space in
the bone segment that appears after surgical debridement
and curettage, aiding in bone repair ( osteoconductive
properties ).
At the same time, this treatment reduces length of stay and
health care costs associated with these infections.
P23
Dislocation of preformed antibiotic-loaded cement spacers: etiological factors and clinical
prognosis
Guillem Bori 1, Ester Garcia-Oltra2, Sebastian Garcia 1, Alex Soriano2
1
Hospital Clinic De Barcelona. University Of Barcelona, Barcelona, Spain
2
Hospital De Berga, Berga, Spain
33rd Annual Meeting of the European Bone & Joint Infection Society
Abstracts Posters
Aim: The aim of our study was to: (A) assess the factors associated with dislocation of the pre-fabricated impregnated
polymethylmethacrylate Spacer-G and (B) its clinical prognosis.
Methods: We have retrospectively reviewed all the patients
with hip infections who were treated in our third level educational hospital from 2000 to 2011. Seventy-four spacers
were reviewed.
Results: Acetabular bone defects, proximal femoral cementation of the spacer and its relationship to the size of the
head spacer were not associated with dislocation. The only
variable that it was possible to associate with dislocation
was when the previous stem, prior to the spacer placement,
was a cemented stem. In patients who experienced a dislocation, infection was not cured during the interim period
more frequently than patients who had not experienced a
dislocation (P=0.001) and the final clinical hip evaluation
was also worse (P<0.001).
Conclusions: The study concludes that the surgeon should
assess different surgical aspects in order to avoid mechanical complications such as dislocation and its consequences.
P24
Incidence, trends and outcome of deep prosthetic joint infections in two community
hospitals in the netherlands, 16 years retrospective data
Lieke de Vries1, Walter van der Weegen2, Dirk Das2, Jeroen Steens 1
Westfriesgasthuis, Hoorn, Netherlands
2
St Anna Hospital, Geldrop, Netherlands
1
Deep prosthetic joint infections have major consequences
for patients with a hip or knee prosthesis. Such infections
may lead to re-operation including revision surgery, worsening the quality of life for these patients. To evaluate the
effectiveness of prevention strategies and treatment options, data on incidence, trends and outcome of deep prosthetic joint infections are important. Few studies described
these data in a large patient cohort. Therefore we retrospectively collected data in two community hospitals in the
Netherlands on all episodes of deep infections after primary
hip and knee replacements over a 16-year period (1997 to
2012). In 105 of 8320 hip replacements (1.26%) and 62 of
6243 knee replacements (0.99%) a deep infection developed. The most common infecting micro-organisms were
staphylococcus aureus (23.0%), staphylococcus epidermidis
(9.7%) and coagulase negative staphylococcus (9.1%). 129
infections arose within 3 months after surgery, 26 between
3 to 12 months and 12 after 1 year of surgery. 132 of 167
patients (79.0%) were initially treated with debridement
and irrigation. Revision surgery due to infection was performed in 45 of 105 infected hip prostheses (42.9%), and in
24 of 62 infected knee prostheses (38.7%). Some variance in
treatment strategy and treatment outcome were observed
between the two hospitals. In conclusion, our baseline incidence rates of deep prosthetic joint infections for patients
with a hip or knee prosthesis were in line with literature
data. Our data showed that debridement and irrigation in
acute prosthetic joint infections may lead to retention of the
prosthesis in a majority of cases. This large series of cases
will hopefully assist in future decision making in prosthetic
joint infections.
P25
Septic arthritis in paediatrics in concepcion, chile. Review of 5 years
Pablo Schaufele1, Andres Ibieta1, Daniel Pineda2, Claudio Figueroa3, Consuelo Peirano3
1
Guillermo Grant Benavente´S Hospital - University Of Concepción, Concepción, Chile
2
Guillermo Grant Benavente´S Hospital, Concepción, Chile
3
University Of Concepcion, Concepción, Chile
Aim: Given the epidemiological and treatment changes
that have occurred in the infectious diseases we decided to
evaluate the management of Septic Arthritis (SA) in our unit.
Material and method: A retrospective study of 50 records
was carried out, 47 with diagnosis of entrance of SA and 3
with diagnosis of another pathology that turned out to be a
SA, among the years 2009 and 2013 in our unit.
Results: 42 only fullfilled the requirements to be classified
as SA (Clinic features of infection, articular localization and
laboratory exams). 69% males, 15 (34.9%) located in hip
(33.3% in infants) and 15 (34.9%) knee (66.7% preschool).
Only 5 had clinically predisposing conditions (trauma). The
half time of clinical evolution foresaw to diagnose it was of
3,79 days (range between 3 and 12 days). The main symp-
September 11-13, 2014 - Utrecht - The Netherlands
125
Abstracts Posters
tom that motivates the medical attention in hip SA was
fever (93.3%) so as in knee and ankle (73,3% and 87,5%
respectively) accompanied by limping, negative to walk or
weight wearing (73,3%) so as knee and ankle (46,7% and
50% respectively). The joint blockage occurred in 93.3% of
the hip SA, 20% and 50% of knees and ankles respectively.
Laboratory exams: WBC count was elevated in 53% of the
hip SA, 60% knee SA and 78, 5% ankle SA; CRP higher than
20 mg/dl in 73,8% of patients. Only 20% of the hips met Kocher criteria for SA modified by Caird, as well as knee. Blood
cultures were positive in only 32% and the Staphylococcus
aureus was the most frequent. Ultrasonography was performed in 11 hips being positive only 7. No patient received
dexamethasone. Almost all patients had a 7 to 9 days course
of intravenous antibiotics (oxacillin + amikacin) and then
completed 4 weeks with oral oxacillin. Almost all patients
recovered without sequel.
Conclusions: Blood cultures should be obtained prior the
administration of antibiotics. The Staphylococcus aureus is
the most frequent germ involved in this process, and may
guide the empiric antibiotic therapy. Ultrasound should be
requested only in deep joints. The drainage of the joint and
the precocious antibiotic treatment solves the case without
sequels. The need of dexamethasone must be analyzed. The
SA must be sought in a limping child with fever.
P26
“Vac instill” and limbs osteomyelitis treatment with bone and soft tissues loss of substance
Domenico Fenga 1, Leonardo Fisichella 1, Francesco Centofanti2, Michele Attilio Rosa 1
1
University Of Messina - Section Of Orthopaedic And Traumatology, Messina, Italy
2
Istituto Codivilla Putti - Gruppo Giomi - Cortina D’ampezzo (Bl), Cortina D’ampezzo, Italy
126
Aim: Before the development of standardized procedures,
in the treatment of large and infected losses of substance, it
was often necessary to do invasive surgical treatments with
the aim of preventing the onset of severe septic processes.
Nowadays, the use of modern techniques of medication associated with the continuous technological development
provides a wide range of treatments to the surgeon.
One of the most innovative methods in this direction is the
“VAC Instill”. This method combines the well known advantages of continuous negative pressure instillation of saline
and / or antibiotics while ensuring cleansing and regenerative capacity of the loss of substance.
Methods: From 2010 to 2013 Authors treated 45 osteomyelitis (35M, 10F), aged from 35 to 70 years: 17 of femur, 9 of
foot, 19 of tibia. Swabs for culture tests per day 0-15-30 were
performed. In all patients it was ensured a thorough debridement (bone and soft parts) of the site of Chronic Osteomyelitis, followed by use of “Vac Instill” for 2 weeks (saline + antibiotics) and a subsequent standard treatment. The pathogens
identified were: Staphylococcus aureus in 21 cases, Pseudomonas aeruginosa in 9 cases, mixed flora in 15 cases.
Results: After a median follow-up of 120 days 17 patients
healed, 19 had an improvement of the loss of substance,
and a disappearance of the bacterial load. In 9 patients no
improvement was observed and they required additional
traditional surgical time. In 15 cases out of 45, skin coverage
with vascularized flap was subsequently performed. Reduction of the bacterial load, subsequent reduction of antibiotic
therapy, increased angiogenesis and a persistent bacterial
eradication, were the objectives pursued by the Authors. The
VAC dressing can be properly secured in all parts of the body
affected by the septic process, ensuring a sufficient odor control and improved personal hygiene. This method allows also
an outpatient treatment with a lower impact of running cost.
Conclusions: “VAC Instill” promotes a therapy for the automated management of infected wounds, allows continuous
administration and automatic removal of liquids, ensuring
the cleaning of the wound bed and facilitating removal of
infected material, topical therapy in deep wounds is also
facilitated. According to the positive experience desumed,
the efficacy of this innovative technique in the management of infected large losses of substance was proved, by
improving their management, always in association with a
no less important thorough surgical debridement.
33rd Annual Meeting of the European Bone & Joint Infection Society
Abstracts Posters
P27
Antibiotic cement-coated intramedullary nails for the treatment of infected nonunions
Tobiáš Judl 1, David Jahoda 1, Ivana Jahodová2, Pavel Melicherčík1, Ivan Landor 1
1
st Orthopeadic Clinic, University Hospital Motol, Prague, Prague, Czech Republic
2
The College Of Nursing O.P.S., Prague, Prague, Czech Republic
Aim: Infected nonunions are one of the most feared complications of trauma surgery. We have to clean infectious
focus and also ensure the stability of nonunion. To stabilize
the nonunion are generally recommended external fixators.
In certain situations it isn’t possible to use both due to the
location and the condition of the soft tissues. The solution
is to use an implant coated. Commercially available gentamicin impregnated nails exclude the preventive antibiotic
doses (is not currently available on the market), and therefore we prefer the antibiotic cement-coated intramedullary
nails. This will ensure the application of local antibiotic carriers, together with the stabilization of an infected nonunion.
We have experiences with nails individually prepared in factory∗ and also with antibiotic cement-coated nails directly
in the operating room. This method is suitable for early
surgery, in which we can not wait longer to coat the nail in
a specialized factory. The manual nail coating process presented by us is certainly more flexible and cheaper. Factory
preparation but delivers more standardized results.
Methods: From December 2011 to December 2013 we used
antibiotic cement-coated nails in 15 patients (10x nails individually prepared in factory*, 5x manual nail coating). We
used bone cement with the addition of gentamicin, vancomycin or tigecycline (by sensitivity). These patients were
prospective registered in a database and the cases were retrospectively reviewed.
Results: Patients included in the study consisted of 12x male
and 3x female. We used 7x (46,6%) cement-coated femoral
nail, 5x (33,3%) cement-coated retronail for ankle arthrodesis and 3x (20%) cement-coated tibial nail. One patient
was operated two times (for two-sided infected nonunion
femur). Failure was noticed in 2 cases; that means an overall
rate of success of 87,7%.
Conclusion: The use of antibiotic cement-coated intramedullary nail in our opinion belonge to the spectrum of operation solving infected nonunion of long bones. This surgical
method can significantly accelerate the course of treatment
and reduce the number of operations. Compared to the use
of external fixation it solves the problem of infection in the
medullary cavity too.
*Tecres®
Supported by the project (Ministry of Health, Czech Republic) for conceptual development of research organization
00064203 (University Hospital Motol, Prague,Czech Republic).
127
The use of cement-coated nail for infected nonunion of the femur
P28 (not presented)
Long-term results of the new method of tibio-calcaneo-naviculo arthrodesis after
astrogalectomy
Chingiz Alizada ,Farhad Alizada
Azerbaijan Scientific Research Institute Of Traumatology And Orthopaedics, Baku, Azerbaijan
Study objectives: The objective of this research is to study
the effectiveness of a new method of tibio-calcaneo-naviculo arthrodesis (TCNA) in patients with osteonecrosis or
osteomyelitis of talus after its removal.
Materials and Methods: The new method of TCNA has ben
performed in 9 patients with different forms of osteomyelitis and fracture of the talus after its removal between 2004
and 2013. The average age of the patients was 39.2 years. 2
patients had posttraumatic septic arthritis and osteomyelitis of the talus, 2 patients had hematogenous osteomyeli-
September 11-13, 2014 - Utrecht - The Netherlands
Abstracts Posters
tis, 2-postoperativ osteomyelitis of the talus. 3 patients had
fracture of the talus- 2 patients had an open comminuted
fracture-dislocation and 1 patient had a simple comminuted fracture-dislocation of the talus. In all patients fixation
was performed by wire-rod external fixator (WREF).
Surgical technique: After astrogalectomy and debridement
in patients with chronic osteomyelitis the cartilages of tibia
and articular surface of calcaneo and naviculo bones were
resected. In 3 patients with fracture-dislocation of talus resection of articular cartilages was performed only in front
and back edges of tibia.
At the edge of the navicular bone a slot has been made.
The second slot was made through facies artiсularis talaris
posterior os calcaneos. Thus, the back edge of tibia was implanted into the slot in the os calcaneos and the front edge
-on the slot in the navicular bone. The WREF was used to
stabilise a TCNA.
Results: The average duration of fixation with WREF was
between 4 ±0.5 months. Septic-inflammatory process was
eliminated in all patients; no complaints of pain were registered. Union was achieved in all patients. The average limb
shortening in patients after arthrodesis was 2.5 ± 0.5 cm.
Deformity and skin folds in the joint area were minimised.
Conclusion: Our 9-year study shows that the new method
of arthrodesis after astrogalectomy permits to considerably
reduce shortening of the lower extremity and deformity in
the arthrodesis area. Patients can use usual footwear and
walk without any support. The results that we have achieved
allow recommending usage of the new method of arthrodesis after astrogalectomy.
P29
Septic arthritis after articular infiltration
Gustavo Lucar, Rafael Tibau, Gabriella Bucci, Maria Tibau
Hospital De Mataró, Mataró, Spain
128
Intraarticular infiltration as symptomatic treatment in degenerative musculoskeletal pathology is quite widespread
and usual practice due to its easiness and results. Septic
arthritis is one of the most feared complications, although
usually quite uncommon, its consequences are severe and
normally require surgical treatment.
The aim of the study is to evaluate the diagnosed cases of
septic arthritis after infiltration as well as its evolution and
characteristics.
It has been carried out a retrospective cases review of septic arthritis diagnosed at our institution pointing out on the
type of germ, the treatment performed and the outcome
We report 11 cases of septic arthritis, all of which were initially treated with arthroscopic debridement, excluding
one case which presented septical myofasciitis associated.
Four of them required one reintervention. All the surgical
procedures were followed by an antibiotherapy regimen.
The most common germs were MSSA (6 cases) followed by
Streptococcus sp (3 cases) and 1 case of Abiotrophy sp.
Seven of the treated patients had a remission of symptoms
with a single arthroscopic debridement. Four required additional debridement in which two cases were performed
arthroscopically and the other two were by open surgery
with good results except one case of death due to severe
sepsis. No articular changes were found comparing the images prior and after the infection.
Post infiltration infections are an uncommon entity in our
common practice but with serious consequences such as
myofasciitis, sepsis and death, in the cases studied early
treatment does not appear to alter the state prior to the
articular infiltration. Arthroscopic debridement followed by
an antibiotic regimen is a valid technique for the treatment
of septic arthritis. Sometimes, more than one single procedure has to be carried out.
P30
Stimulation of regenerative processes in chronic wounds with platelet-rich autoplasma - an
experimental and clinical study
Vladimir Obolenskiy 1, Darya Ermolova2, Leonid Laberko3
1
City Hospital 13, RNRMU, Moscow, Russia
2
RNRMU, City Hospital 13, Moscow, Russia
3
RNRMU, Moscow, Russia
Aim: to study the effectivenes of platelet rich plasma (PRP)
for clinical use.
Methods: Blood collected from a peripheral vein of the pa-
tients with chronic wounds of various etiologies was usedas
a biological material. PRP was obtained by separating blood
with the use of BTI equipment*). Whole blood platelets were
33rd Annual Meeting of the European Bone & Joint Infection Society
Abstracts Posters
stained with vital fluorochrome dye for further morphofunctional analysison a fluorescence microscope. Concentration of platelet-derived growth factor (PDGF) in blood
serum was determined by enzyme-linked immunosorbent
assay (ELISA) using reagents «Qantikine, Human PDGF-BB
Immunoassay» and system «Multiskan ascent». Proliferative
activity of human fibroblast culture M-22 was assessed in
the wells containing different amount of serum PDGF and
also using fluorochrome vital dyes.
In a clinical study analysis of the treatment outcomes of
81 patients with chronic wounds (CW) of various etiologies was performed. For the treatment of the 44 patients
(experimental group: 17 males, 27 females, the mean age 56.0±3.1; trophic venous ulcers (TVU) 3, ulcers of combined
etiology (CEU) 8, related to diabetic foot syndrome (DFS)
12, scar-trophic ulcer (STU) - 14 and bedsores (BU) - 7, the
mean CW area was 90.2±14.1 cm2), we used PRP flat clot
therapy starting from phase II of wound healing process.
Frequency of dressing changes once in 7 days, which allows
patient transfers to outpatient care. For the treatment of the
37 patients (control group: 17 males, 20 females, mean age
was 69.5±2.2; TVU-5, CEU-12, DFS-8, STU–5, BU-7; 79.6±12.3
cm2), traditional topical agents were used.
Results: A direct correlation between concentration and
morpho-functional parameters of whole blood platelets and
concentration of PDGF in the serum has been observed. Degranulation of platelets is associated with the massive release
of PDGF. The study finding was that the content of PDGF in
one well equal to 150 pg is associated with the maximum
gain of proliferative activity of fibroblastswith their viability
being preserved; at the higher PDGF concentrations fibroblasts viability decreased and cells death was observed.
In a clinical study 85.4% patients achieved complete CW
epithelialization within 46.4±4.3 days (experimental group).
In the control group only 11.8% patients achieved wound
epithelialization within 3 months. Mean duration of hospital stay was 11.0±2.5 days in the experimental group and
23.1±1.5 days in the control.
Conclusions. These data allow recommending the clinical
use of PRP for stimulation of the regenerative processes.
*) BTI, Spain
P31
Could be useful to perform an urinoculture-sediment to patients with dementia and femoral
neck fracture at admission to hospital?
Lluís Font-Vizcarra 1, David Martí2, Laura García-Nuño 1, Carles Villamil2, Araceli González-Cuevas 1, Silvia Capilla2, Vicenç DiazBrito 1, Xavier Oncins2, Pere Torner2, Juan Castellanos 1
1
Parc Sanitari Sant Joan De Deu, Sant Boi De Llobregat, Spain
2
Hospital Parc Taulí, Sabadell, Spain
Aim: An active urinary tract infection (UTI) prior to the surgery, is a well documented independent risk factor of acute
prosthetic joint infection. However, patients with dementia,
usually can not explain the symptoms of dysuria, so presumably, a high number of UTI could be not detected. The
aim of the study was to compare the rate of positive urine
culture and/or sediment at admission in patients with femoral neck fracture with and without dementia.
Methods: An urinoculture and sediment were performed
to all patients with a femoral neck fracture when they were
admitted to hospital. Variables like sex, age, institutionalisation, dementia and other comorbidities, post-surgical complications, post-surgical UTI and in-hospital dead were collected. The results of cultures were retrospectively revised.
Statistical comparisons between patients with and without
dementia were performed using SPSS v17 program.
Results: A total of 155 patients were included (56 with
dementia). The rate of urinoculture positive was 33.9% in
patients with dementia and 15.2% in patients without dementia (p=0.009). The rate of pathologic sediment was also
higher in patients with dementia: 32.7% vs 16.1% (p= 0.036).
Although the prevalence of diagnosed UTI after the surgery
was higher in patients with dementia 10.9% vs 4.1%, this
difference was not statistically significant (p=0.169).
Conclusion: Patients with dementia have a statistically
higher rate of pre-surgical positive urinoculture and pathologic sediment comparing with patients without dementia.
However, the rate of UTI was not statistically higher, so, in
theory a number of UTI could be infra-diagnosed because
the difficulty of some patients with dementia to explain
their symptoms. Although more studies with a higher number of patients for collecting the acute prosthetic joint infection rate, are necessary, it seems reasonable to recommend performing an urinoculture and/or sediment at the
moment of admission of these patients.
September 11-13, 2014 - Utrecht - The Netherlands
129
Abstracts Posters
P32
Clinical burden of bone and joint infection at a tertiary care hospital in an asian megacity
Mansoor Khan 1, Mohammad Chinoy 1, Syed Aslam 1, Ali Jillani 1, Mehreen Iqbal2, Syed Kamran Ahmed 1
1
The Indus Hospital, Karachi, Pakistan
2
Emory University, Atlanta, United States
130
Aim: The burden of bone and joint infections is not known
in the developing world. The absence of such data prevents
proper allocation of resources to prevention and treatment
of these serious problems. The purpose of this study is to
attempt to provide some data to give an idea of the magnititude of the problem of Orthopaedic infections
Methods: Our institution is a 150 bed tertiary care facility with a 2.5 million multi ethnic population catchment
area. We did a retrospective review of our electronic medical records of all patients admitted between Sept 2007 to
May 2013 with the following primary diagnoses using ICD
10 codes : osteomyelitis, septic arthritis, device-associated
or prosthesis infection, and surgical site infections occurring as complications or arthroscopies, sequestrectomies,
arthroplasties and external bone fixations. Information extracted included gender, age, number of hospital admissions, length of stay, pathogens isolated, as well as hospital
free days.
Results: Out of 7613 Orthopaedic admissions, 661 (8.7%)
were for infections during the study period. Almost 30%
of the patients had multiple admissions. Primary diagnosis
at admission ranged from osteomyelitis (58.1%) , infected
implants (12.1%), Neglected open fracture wounds (12%)
Septic Arthritis (8.5%). Patients with Tuberculous arthri-
tis were (2.1%). Patients presenting with infections of surgery done at our institution were (7.3%), Pathogens were
isolated in 60% of the patients; of which 78.2% involved a
single pathogen (309 / 395pts). Most common pathogens
isolated were Staph Aureus (38.8%); Pseud Sp (15.7%); Klebsiella (13.6%). Of the Staph. Isolates (26%) were Methicillin
resistant (MRSA)
Conclusion: We know from recent literature, that surgical
disease burden and specifically orthopedic disease burden
has been described as an area of immense need and focus
within the global health context.. Given what we know from
this study we conclude that patients with Orthopaedic infections is an un assessed burden. Excluding TB infections
and patients who acquired infection at our institution,
90.7% of patients came to our institution with infections acquired elsewhere. This may reflect quality of care at other
institutions, including inappropriate antibiotic usage
References
•
•
•
•
Lipsky BA,: Infect Control Hosp Epidemiol., 2007. 28(11): p. 1290-8.)
Rubin RJ. Emerg Infect Dis.,1999. 5(1): p. 9-17.)
Key words: Orthopaedic Infections, Clinical burden, South Asia
Acknowledgements: We would like to thank the Department of Microbiology as as the Indus Hospital Research Center
P33
WITHDRAWN
P34
Hip complaints caused by osteoarticular tuberculosis. Diagnostics and treatment in three
patients
Rasmus Cleemann1, Kristian Behrndtz2, Martin Lamm2, Christian Wejse3, Klaus Kjaer Petersen2
1
Department Of Orthopaedic Surgery, Aarhus University Hospital, Silkeborg Regional Hospital, Silkeborg, Aarhus, Denmark
2
Department Of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark, Aarhus, Denmark
3
Department Of Infectious Diseases, Aarhus, Denmark
Aim: We here present three patients with osteoarticular infection caused by Mycobacterium Tuberculosis. Common
complaint was hip pain but with three different clinical presentations and surgical treatments.
Methods:
From 2011 through 2013 we found three immunocompetent patients referred with hip pain caused by Mycobacteri-
um Tuberculosis. Medical files, cultures, tests and radiological images were retrospectively studied.
Results: 1) A 13 years old boy of sub-Saharan heritage, was
hospitalized with weightloss, fever and chronic pain in the
left hip.
Mantoux and -interferon tests were poitive. PET-CT
displayed activity in lungs, liver, spleen, left hip and ac-
33rd Annual Meeting of the European Bone & Joint Infection Society
Abstracts Posters
etabulum. Pulmonary aspirate was culture-positive with
M.Tuberculosis. MRI revealed necrosis of the left hip. Diagnose was miliary tuberculosis.
Standard four-drug antituberculous chemotherapy was
started, followed by a two-stage uncemented Total Hip Artroplasty (THA). Index operation revealed extensive caseous
necrosis, Polymerase Chain Reaction (PCR) and culture positive for M.Tuberculosis.
The acetabular component was revised 18 months later due
to loosening. Biopsies were culture negative but PCR positive for M.Tuberculosis and microscopy showed acid fast bacilli. Antituberculous treatment was reinstituted.
2) A 22 years old man of sub-Saharan origin presented with
3 months of pain and tightening sensation in the left hip
and buttock. He presented with a 30 cm prominence i the
left gluteal region.
Pelvic x-ray showed a lytic leasion in the left iliac bone. A
CT scan visualized a confluent process from the left gluteal
muscle through the iliac bone and into the ilipsoas muscle. PCR and smear microscopy of abces material showed
M.Tuberculosis. Abces and iliac sequester was openly
drained and standard four-drug antituberculous chemotherapy instituted. Abces material presented as a liquid.
3) A 79 years old caucasian danish man was hospitalized
with waisting, fever and coughing. Three months earlier he
underwent his 4th THA revision of the left hip due to aseptic
loosening. Index operation was 33 years prior.
A CT showed bilateral pulmonary activity and left iliac bone
and hip affection. Positive PCR broncho alveolar lavage
and -inteferon diagnosed miliary TB. Antituberculous chemotherapy was started, two months of four-drug and ten
months of two-drug treatment. He relapsed two months
after treatment cessation. Iliac bone biopsi was PCR positive
for M.Tuberculosis. 12 months of antituberculous chemotherapy was initiated with moxifloxacin added..
Conslusions: Remember tuberculosis! Tuberculosis should
be suspected in patients from endemic and non-endemic
areas with osteoarticular complaints, despite a history of
vaccination and immunocompetence.
Acknowledgements
The authors have no conflict of interest.
P35
WITHDRAWN
131
P36
Is testing for oxacillin susceptibility really irrelevant in Kingella kingae?
Marko Pokorn1, Manica Muller Premru2
University Medical Centre Ljubljana, Department Of Infectious Diseases, Ljubljana, Slovenia
2
Institute Of Medical Microbiology And Immunology, Medical Faculty Ljubljana, Ljubljana, Slovenia
1
Background: K. kingae is an important cause of osteoarticular infections (OAI) in young children. In this age group,
flucloxacillin (FCX) is usually given as empirical antibiotic
therapy for suspected OAI if the child is immunized against
H. influenzae type b. FCX is predominantly active against
gram-positive cocci, among gram-negative bacteria only
Neisseria family is usually susceptible to this drug.
Methods: We tested two K. kingae septic arthritis isolates
for oxacillin susceptibility using the E-test and compared
susceptibility results with clinical effect of FCX treatment,
given empirically. Since no standard breakpoint values are
known for oxacillin and K. kingae, reference values for S. aureus (resistant, MIC ≥4 mg/L) were used.
Results: In the first case, a 20-month-old boy with K. kingae
arthritis of the knee, there was no improvement after empirical treatment with FCX and the isolate’s MIC to oxacillin was subsequently shown to be 8.0 mg/L. Dramatic improvement was seen after changing treatment to penicillin
G (MIC 0.094 mg/L). The patient completed treatment with
oral penicillin. In the second case, a 16-month-old girl with
K. kingae arthritis of the knee, systemic and local signs improved on FCX treatment and the isolate’s MIC of oxacillin
was 3.0 mg/L (MIC of penicillin was 0.032 and of ampicillin 0.094 mg/L). The child completed treatment with oral
amoxicillin. Both children recovered without sequelae.
Conclusion: In a study by Yagupsky et al, 85 K. kingae OAI
isolates were tested for oxacillin resistance and 37.6% were
found to be resistant (using the staphylococcal breakpoint
value of MIC ≥4 mg/L) but no data on treatment were
presented. We believe our results support the use of this
breakpoint value. Nevertheless, FCX should not be used for
treatment of K. kingae OAI, since other drugs are available
that exhibit far lower MICs and are even more suitable (and
palatable) for children. The question remains, should antibiotic treatment be directed against K. kingae in a toddler
with culture-negative OAI that does not respond to empirical treatment with FCX.
September 11-13, 2014 - Utrecht - The Netherlands
Abstracts Posters
P37 (not presented)
Acute osteomyelitis: case series of 10 years
Isidor Marchan, Alfredo Matamala, Emiliano Mora, Robert Cilvetti, Daniel Haro, Lucia Gomez
University Hospital Mutua Terrassa, Barcelona, Spain
Introduction and Objectives: Acute osteomyelitis is a rare
but important infection due to its severity or its complications or sequelae. In early stages it may be difficult to recognize. We reviewed the literature and our experience of the
last 10 years to bring the diagnosis and treatment of this
disease.
Method: Retrospective enero/2003 to marzo/2013, with a
total of 24 patients. Demographic, clinical, diagnostic and
therapeutic variables, as well as monitoring and evolution
are collected.
Results: The mean age was 98 months (range 13-164
months); only 5 patients were younger than 5 years ( 25%).
The male / female ratio turned out 17/7. On location, 75 %
were in the lower extremities and 20% had pelvic involvement. There was history of trauma in 33% of cases , and entry door clear skin in 33% of cases. As for the clinic, the pain
was constant (100 % of cases) and fever occurred in 85% of
patients (mean 4.3 days prior to diagnosis time). Complications encountered 4 patients jurisdiction as abscess ( 16%),
132
and 3 associated (12%) arthritis. Analytically, the average
number of leukocytes was 9555/mm3, CRP 68 mg / L and
ESR 41 mm / h, noting that only 20% had leukocytosis. Germ
was isolated in 54% of cases, and in all isolated S. aureus
(12/24 blood culture positive patients , 4/5 patients of bone
material culture). Rx was performed on 75% of cases, bone
scan and MRI at 83% to 70 %. The average hospital stay was
16 days and the average of intravenous and oral treatment
were 14 and 30 days respectively . Only one patient had sequelae in the form of chronic osteomyelitis with functional
impairment.
Conclusions: In our series include a higher mean age (8
years , in the literature more than 50% are under 5 years)
and pelvic location (20%) and different data to literature. We
note the limited analytical alteration of many patients with
little overt clinics in early stages can delay diagnosis. We also
want to emphasize the importance of trying the etiological
isolation for treatment directed by antibiogram and secure.
P38
WITHDRAWN
P39
Chronic osteomyelitis of olecranon treated with curettage and biologic cement with
antibiotics. A case report
Laura García-Nuño, Araceli González-Cuevas, Ernesto Muñoz-Mahamud, Oscar Izquierdo, Vicenç Diaz-Brito, Juan Castellanos,
Lluís Font-Vizcarra
Parc Sanitari Sant Joan De Deu, Sant Boi De Llobregat, Spain
Aim: Classically, chronic osteomyelitis with intrabone collection and bone sequestrum has been treated with radical
debridement. However, to leave the cavity of bone unfilled
could promote recurrences or new collections. Use bone cement with antibiotic to fill the cavity was an option but due
to the absence of reabsorption of this stuff, the bone never
regenerates. With the advent of biologic cements that could
be mixed with antibiotics, a new treatment option with osteoconductive proprieties is possible. We present our experience in a case report.
Methods: We present a 60 year old patient with a chronic
osteomyelitis caused by Pseudomonas aeruginosa in left
olecranon. Multiple debridements had failed previously
with recurrence of fistula. Before performing a radical exci-
sion of all the olecranon, a curettage of all the cancellous
bone and part of the cortical was performed. The generated
cavity was filled with synthetic high purity calcium phosphate mixed with gentamicin. Two week of dual intravenous antibiotic treatment with cefepime and ciprofloxacin
followed by 6 weeks of oral treatment with ciprofloxacin
was prescribed.
Results: The outcome was satisfactory until healing. In the
last control, at 12 months, the patient was asymptomatic
with a complete articular balance of the joint without clinical nor analytic signs of active infection. Complete substitution of calcium phosphate cement by mature bone was
observed in the last X-ray control.
Conclusion: Despite the good results documented in this
33rd Annual Meeting of the European Bone & Joint Infection Society
Abstracts Posters
case report, further studies are necessary to define the real
role of these biological cements in the treatment of bone
infections and to evaluate the benefits of them compared
with classic treatments.
P40
Elution and efficacy of colistin when combined with a synthetic calcium sulfate
Michael Brayford1, Phill Laycock2, John Cooper2
Industry, Staffordshire, United Kingdom
2
Biocomposites Ltd., Staffordshire, United Kingdom
1
Aim: The emergence of multi-drug resistant Gram-negative
bacteria is a serious threat to health. The polymyxin antibiotic colistin may be the last line of defence against these
pathogens in the 21st century1. Local release of antibiotics
from calcium sulfate to the site of infection, enables high
concentrations many times MIC, while systemic levels and
associated side effects remain low. The potential of calcium
sulfate to mix with, set and elute colistin in bactericidal concentrations was established.
Method: The colistin sulfate containing beads were prepared using a commercially available high purity calcium
sulfate hemihydrate (CS) – CaSO41/2H2O (Stimulan Rapid
Cure®*). 1g of beads were put into vials containing 2ml
phosphate buffered saline (PBS) at 37oC. Total exchange of
the PBS containing eluted antibiotic was performed daily,
out to 21 days, and replenished with fresh PBS. Mixing and
setting characteristics were measured and colistin elution
levels quantified by LC-MS. Zone of inhibition (ZOI) testing
of the antibiotic loaded beads was carried out against Pseudomonas aeruginosa NCTC 13437 and Acinetobacter baumannii NCTC 13424.
Results: The CS mixed and set with colistin sulfate (20gm
+ 400mg) within 10 minutes. Levels of colistin in the eluate
samples peaked at 5109µg/ml on day 1 but had dropped
to 1.4µg/ml by day 7. Eluate levels remained above MICs
for 100% of 561 P. aeruginosa isolates out to 3 days. For A.
Baumannii, eluate levels were above MICs for 100% of 31
isolates out to 3 days and 74.2% out to 7 days. Both microorganisms tested for ZOI showed susceptibility to colistin
eluted from CS beads. ZOIs of 19 mm were observed for
Pseudomonas and 18 mm for Acinetobacter. Higher sustained colistin elution levels were achieved when rifampicin
was added as a second antibiotic, achieving levels above
MIC out to 21 days for 91.6% of 561 P.aeruginosa isolates
and 93.5% of 31 A Baumani isolates.
Conclusions: Colistin sulfate will mix, set and elute from
synthetic high purity calcium sulfate at bactericidal levels.
Literature has demonstrated successful clinical outcomes
when colistin is administered in this way both alone and
synergistically with other antibiotics3,4. Further work to
investigate elution characteristics of colistin/CS beads combined with other antibiotics is warranted.
References
* Biocomposites Ltd.
1. Biswas S. Expert Rev Anti Infect Ther. 2012; 10(8): 917-934
2. Walkty A. Antimicrobial Agents and Chemotherapy 2009; 53(11):
4294-4926.
3. Parihar M. Journal of Orthopaedic Case Reports 2013; 2:26-31.
4. Stanzani M. Journal of Medical Microbiology (2007), 56, 1692–1695
All work was funded by Biocomposites Ltd.
P41
A severe case of paediatric group a streptococcal osteomyelitis in varicella
Andrzej Krzysztofiak1, Renato Toniolo2, Elena Bozzola1, Laura Lancella1, Elena Bellelli1, Elena Boccuzzi1, Alberto Villani1
Pediatric And Infectious Disease Unit, Pediatric Dep. Bambino Gesù Hospital, Rome, Rome, Italy
2
Orthopedic Unit, Bambino Gesù Hospital, Rome, Rome, Italy
1
We report an unusual paediatric case of streptococcal osteomyelitis with a severe outcome as a complication of varicella.
A 15-month-old girl was admitted to our Unit because of
high fever, pain and joint immobility of her right elbow and
left ankle. Upon admission the patient presented pustules
with highly infected lesions on her back, trunk, arms and
face. Physical examination revealed marked swelling with
diffused tenderness and local warmth at both the right
elbow and the left ankle. The patient at admission had a
leukocyte count (WBC) of 17,940 mmc, C-reactive protein
(CRP) of 17.15 mg/dl and erythrocyte sedimentation rate
(ERS) of 50 mm/h. Empirical antibiotic therapy with ceftriaxone and amikacin was prescribed. Conventional X-ray revealed swelling at the right elbow, left wrist and feet as well
as a fragmented and irregular profile of the right ulna distal
metaphysic and the left fibula. Magnetic resonance imag-
September 11-13, 2014 - Utrecht - The Netherlands
133
Abstracts Posters
ing (MRI) of the elbow revealed massive inflammation of
the joint on the left side, with involvement of the surrounding soft tissues.Three days after admission, ceftriaxone and
amikacin were replaced by ampicillin, owing to a positive
blood culture for Group A beta-hemolytic streptococcus
(GABSH). Two weeks following the initiation of the ampicillin treatment, laboratory tests revealed the WBC count to be
11,000 mmc, CRP 4.63 and ERS 100 mm/h. Due to the lack
of improvement in the patient’s clinical condition, ampicillin therapy was changed to treatment with linezolid.This
led to pain relief and a decrease in the swelling. Four weeks
after the initiation of linezolid therapy, the patient was discharged with oral administration of linezolid. However, 15
days later, the patient was readmitted due to right elbow
pain and swelling. Radiological examinations (X-ray and
MRI) revealed bone destruction of the ulna distal metaphysic, compatible with destructive osteomyelitis. The residual
proximal stump was diverted externally, and both the lamellar and diaphyseal distal stumps were fragmented. The
orthopaedic physician intraoperatively reduced the antero-
lateral dislocation of the right
radius and put it into a cast. One
month following the surgery, Xray examinations showed severe
right ulna destructive outcomes,
with just a minimal residual
proximal and distal fragments.
Varicella complications are rare,
but in some patients they may
be severe, requiring hospitalization. The frequency of varicella infection complicated by
invasive GABSH disease in children has been documented to
be 6–17%. Recently, numerous
studies have documented an increasing incidence and severity
of GABSHS infections.
Elbow: radiological outcome
P42
Purulent gonarthritis resulting from a h1n1 virus pneumonia
Ulrich Illgner1, Ludwig Bause1, Veith Krenn2
Clinic For Rheumaorthopaedic Surgery St Josef Stift Sendenhorst, Sendenhorst, Germany
2
Center For Histology, Cytology And Molecular Diagnostics Trier, Trier, Germany
1
134
Introduction: There have not been papers about orthopedic complications during pneumonia due to influenzavirus
H1N1 so far.
Aim: Goal of this paper was to show a new complication
of H1N1 virus infection that has not been published so far.
Methods: A 44y old male showed uncharacteristic systemic
symptoms. During arthroscopy betahemolysing Staphylococcus gr. A and Acinetobacter were found and the histopathological diagnosis of a infectious bacterial synovialitis
was seen. There was a worsening of the patient´s general
condition though antibiotic treatment according to the re-
sistogram. Influenzavirus A H1N1 was proven in a sample of
the nose and was successfully treated with oseltamivir.
Results: A male patient showed a bacterial infection of
his knee and a worsening of his general condition though
surgical debridement and antibiotic treatement was performed. Only after detection of his H1N1 virus pneumonia
and treatment with oseltamivir his condition improved.
Conclusions: If fever and elevated infection markers resist a
search for the focus has to be performed including unlikely
diseases like a influenzavirus A H1N1.
P43 (not presented)
Management of an infected nonunion of a high tibia opening wedge osteotomy with
2-staged implantation of a rhk prosthesis: a case report
Sandrine Mariaux1, Alexandre Burn2, Lionel Brun3, Christophe Tissot1, Olivier Borens1
CHUV, Department Of Orthopaedic Surgery And Traumatology, University Hospital, Lausanne, Switzerland
2
Hôpital Neuchâtelois Pourtalès, Division Of Trauma Surgery, Department Of Surgery, Neuchâtel, Switzerland
3
Stadtspital Triemli, Zürich, Switzerland
1
Aim: Few cases are described in the literature concerning
treatment of infected nonunion after high tibial osteotomy
(HTO). We present one case.
Methods: A 49 year old female obese patient (BMI 41),
known for medial opening wedge HTO for varus gonarthritis in 2009, developped an infection of the operative
33rd Annual Meeting of the European Bone & Joint Infection Society
Abstracts Posters
site early postoperatively. Microbiology was positive for β
hemolytic group B Streptococcus and Enterobacter cloacae,
resistant to coamoxicilin. The infection was treated with oral
antibiotics.
In 2010, due to painful nonunion of the HTO, she was operated for hardware removal, allograft and plate fixation. At
1 year follow-up, x-rays showed a broken plate with slight
epiphyseal translation. As the patient could walk with discrete pain, she refused a new operation.
In 2013, she consulted with a painful, red and swollen leg
with impossible weight bearing. After initial unsuccessful
oral treatment, she was hospitalised for intravenous antibiotics. Ultrasound showed a 7x2.5 cm collection adjacent
to the HTO plate. Therefore, debridement and hardware
removal were performed. All biopsies remained sterile and
PCR revealed Streptococcus dysgalactiae.
After multiple debridements and V.A.C. dressings, the
wound was closed and adequate oral antibiotic treatment
was started.
2 weeks later, the patient had increased knee pain and CRP
and wound dehiscence. CT-scan showed a purulent collection around the nonunion with knee effusion. Knee puncture
produced a translucent, bloody liquid. Open debridement
was performed combined with arthroscopic synovectomy.
The patient was then transferred to a tertiary care hospital,
where she had a 2-stage operation. First the articular infected block was resected and replaced by a non-articulating
gentamycin/vancomycin impregnated cement spacer. At
this stage primary closure of the wound was possible. After
3 weeks, a RHK prosthesis was implanted combined with a
gastrocnemius muscle flap to cover the soft tissue damage
adjacent to the previous HTO.
Results: In our case, the gonarthritis was too severe to consider another attempt of osteosynthesis. A cement spacer
was used to avoid retraction of soft tissues and to allow local antibiotic treatment. Considering the bone defect and
the loss of the ligamentous structures of the knee RHK prosthesis was chosen.
Conclusions: Different efficient treatments exist for infected
nonunion after HTO. We performed a 2-staged implantation
TKR with short interval. Indeed, depending on the pathogen and according to its virulence and resistance, early TKR
implantation can be done. However, we lack large studies
for a consensus protocol of treatment.
P44
Early versus late surgical debridement of open tibial fractures: the effect of the 6-hour rule on
infection and non-union. A systematic review and meta-analysis
135
Apostolos Prodromidis, Charalambos Charalambous
Blackpool Victoria Hospital, Blackpool, United Kingdom
Aim: Urgent operative debridement and stabilisation is essential in the treatment of open tibial fractures. Traditionally
it has been recommended that open tibial fractures should
be debrided and stabilised within 6 hours from injury to reduce the risk of infection and non-union. However, the scientific basis of this recommendation has been questioned.
The aim of this study was to carry out a systematic review
and meta-analysis of clinical studies comparing early (6
hours) primary surgical debridement of open tibial fractures, with regards to infection and non-union rates.
Methods: A literature search of MEDLINE, EMBASE, CINAHL
and AMED databases using relevant keywords revealed
5820 studies. After appropriate screening of titles, abstracts
and full studies, 7 studies with a total of 610 patients were
included for analysis.
Results: From the studies meeting the inclusion criteria,
3 (n=365) evaluated overall infection rates and showed
a 12.9% infection rate in the early versus 6.7% in the late
group. Three studies (n=197) evaluated deep infection rates
with a 14.4% infection rate in the early versus 14% in the
late group. Four studies (n=245) evaluated non-union rates
and revealed a non-union rate of 19.5% in the early versus
15.6% in the late group. Meta-analysis showed no statistical
difference between groups.
Conclusions: Systematic review of the available literature
suggests that there is very limited evidence evaluating the
recommendation of debriding open tibial fractures within
6 hours from injury. The main limitation of the published
literature is the large heterogeneity in defining infection.
The limited available evidence suggests that the overall infection rates are similar in fractures debrided
within 6 hours versus those debrided at more
than 6 hours. A prospective cohort study with
strict infection definition criteria and concentrating on deep infection and non-union
rates would be of great value.
Deep infection rate meta-analysis
September 11-13, 2014 - Utrecht - The Netherlands
Abstracts Posters
P45
The Ilizarov treatment of severe infected tibial nonunion
Ciro Pempinello1, Carlo Salomone2, Paolo Mallano1, Salvatore Pagliuca1, Fiorella Martucci3
S.Gennaro Hospital, Department Of Orthopaedic And Traumatology, Napoli, Italy
2
Albenga Hospital, M.I.O.S. (Malattie Infettive Ortopedia Settica), Savona, Italy
3
Cotugno Hospital, Department Of Infectious Diseases, Napoli, Italy
1
136
Aim: The increased incidence of severe high-energy trauma
(road traffic accidents, sports injuries etc.) has resulted in a
huge rise in post-traumatic infectious complications due to
delayed diagnosis or inadequate treatment. In such cases, it
is necessary to perform bone resection and bone transport.
In order to fill the loss of bone substance application of external circular fixator has been evaluated.
Materials and Methods: We present 8 cases of severe septic
tibial non-union, among which, 7 were consequent to road
accidents and 1 to sports injury. The patients (7 males – 1
woman, age between 29 and 56 years) presented MRSA (5
cases), mixed flora MRSA and P. mirabilis (1 patient with a
long history of drug abuse); in 2 cases, the pathogen was
not identified. All were subjected to septic bone resection
with application of bifocal Ilizarov apparatus with bone
transport, in addition to a long cycle of targeted antibiotic
therapy.
Results: The follow-up, including clinical, radiographic and
laboratory tests, was 18-36 months. Healing occurred in 7
cases with consolidation of tibial non-union without any
relapse or recurrence of sepsis; in 1 case there is still tibial
pseudoarthrosis with rigid knee flexion at 90°, relapse of infection with an area of skin necrosis. One patient presented
fatigue failure of 2 wires, two patients presented limb shortening (≤ 2 cm), and 4 patients presented limb shortening (≤
2cm) and deformity in varus-supination of mild degree (≤
30°). The last patient, who had long history of drug abuse,
has been evaluated for limb amputation, on the basis of
poor nursing, persistence of tibial pseudoarthrosis, relapse
of infection, and skin necrosis.
Conclusions: The 8 treated cases show that Ilizarov treatment is most beneficial in cases of infected tibial non-union.
However, the best outcome is closely related to a careful
and regular monitoring of clinical conditions (careful and
slow bone transport, laboratory tests, targeted antibiotic therapy) for the entire period in which the apparatus
is maintained. The Ilizarov frame allows stabilization and
lengthening of the segment with bone transportation, correction of axial deviation and associated soft tissue coverage. Its action is essential in cases of severe loss of bone
stock, such as those that occur after surgical debridement
of infected tibial nonunion.
P46
The influence of local negative pressure on the acceleration phase wound healing process clinical and histological study
Vladimir Obolenskiy1, Alexander Ermolov2, Grigory Rodoman3
City Hospital 13, Moscow; RNRMU, Moscow, Russia
2
RNRMU, City Hospital 13, Moscow, Russia
3
RNRMU, Moscow, Russia
1
Aim: To assess the efficacy of negative pressure wound
therapy (NPWT) in treatment of soft tissues acute purulent
diseases (STAPD).
Methods: Analysis of treatment outcomes of 31 patients
with extensive phlegmons and abscesses was performed.
On admission all patients underwent incision and drainage
of purulent focusand received empirical antibiotic therapy.
On day 3 NPWT was used for the wound (experimental
group: 8 males, 9 females, mean age was 51.5±4.5 years,
mean baseline wound volume 315.2±70.2 cm3, bacterial
contamination level was 107), dressing was changed every
3-4 days, or dressings with traditional topical antiseptics
were used (control: 6/8; 49.1±4.5; 315.4±91.4 cm3; 107), followed by daily dressing change. Following wound decontamination and formation of granulation tissue, secondary
sutures were applied. Bacteriological and histological examination of biopsy wounds were carried out on 1, 3, 7 and
10 days of treatment.
Results: At 1 and 3 days of treatment histology in both
groups was identical. On day 7, in the preparations of an
experimental group - an abundance of histiocytes and fibroblasts, proliferation of capillaries, and in the preparations of the comparison group maintained infiltration of
neutrophils. On day 7 in the experimental group, the mean
wound volume was 96.5 cm3 with bacterial contamination
level 102, while in the control group those were 162.1 cm3
and 105, respectively. Time to applying secondary suturesin
patients of the experimental group was 10.2±1.1 days,
while in the control group it was 18.6±0.6 (sutures were applied in 3 patients only). Mean duration of hospital stay was
33rd Annual Meeting of the European Bone & Joint Infection Society
Abstracts Posters
16.0±1.7 days and 21.6±1.9 days, respectively. Mean cost of
treatment was EUR 1593.93 and EUR 1822.14 per patient,
respectively.
Conclusion: NPWT is a clinically beneficial and cost effective
method of treatment of STAPD.
P47
In vivo selection of a rifampin-resistant propionibacterium sp. Strain during treatment of a
staphylococcus aureus bone and joint infection
Guillaume Aubin, Pascale Bémer, Maeva Lefebvre, Sophie Touchais, Didier Lepelletier, Stéphane Corvec
Nantes University Hospital, Nantes, France
Introduction: Bone and joint infections are usually treated
with antibiotic combination to prevent selection of resistant
bacteria at the infection site. We describe the emergence of
a Propionibacterium species highly resistant to rifampin
during rifampin-levofloxacin therapy.
Case description: A 21 year-old man was admitted for an
open fracture of tibia and fibula in September 2011. Surgical
treatment consisted in placing an external fixator (EF) to the
tibia and intra-medullary wires in fibula.
In December 2011, the patient presented skin necrosis and
pseudarthrosis on the CT scan. The treatment of pseudarthrosis consisted in the removal of the EF and the installation of a plaster boot. Four months later, the second stage
of the surgery relied on consolidation of the tibia using an
intramedullary rod. Five tissue samples were collected and
antibiotic therapy was started using vancomycin and gentamicin. All samples were positive in culture to S. aureus.
All isolates were fully susceptible except for erythromycin.
Intravenous therapy was changed to oral combination therapy with levofloxacin (500 mg/day) and rifampin (1200 mg/
day) for six weeks.
One year later, a pyogenic granuloma developed on the
screw of the ancient EF suggesting an underlying sepsis.
Treatment consisted of material removal associated with
cloxacilline/gentamicin treatment. Four out of five samples
were positive in culture to an anaerobic Gram-positive rod
identified to Propionibacterium sp. using two different mass
spectrometry systems (Vitek MS, bioMérieux, and MALDITOF, Bruker). 16S rRNA and rpoB genes sequencing revealed
a 91% and 90% similarity compared with P. acnes and P. avidum reference sequences, respectively.
This bacterium was resistant to rifampin (MIC > 32 mg/L)
but susceptible to levofloxacin (MIC=0.25 mg/L) and amoxicillin by using E-test method. The treatment was changed
for amoxicillin (6 g per day) for two months. Clinical outcome was favorable.
Characterization of the rifampin resistance was investigated
through rpoB gene analysis. Sequence obtained was compared with the rpoB gene sequence of P. acnes reference
strain (Genbank accession number NC006085). A single
mutation was found in position 440 in cluster I, leading to a
substitution from Arg to His.
Discussion: During treatment, a bacterium highly resistant
to rifampin emerged and was responsible for superinfection,
one year after the S. aureus infectious episode. The acquisition of high level of resistance to rifampicin remains rare in
this bacterium. Microbiologists and physicians should be
aware of the possible emergence of such resistant strains
after long-term treatment by rifampin.
P48
WITHDRWAN
P49
First report of spondylodiscitis due to Listeria monocytogenes
Guillaume Aubin, Pascale Bémer, Magali Brière, David Boutoille, Olivier Ribeyrol, Jocelyne Caillon, Didier Lepelletier, Stéphane
Corvec
Nantes Univsersity Hospital, Nantes, France
Introduction: The diverse clinical spectrum of Listeria
monocytogenes infections includes frequent clinical forms,
such as meningitis, or bacteremia, and uncommon manifestations, such as septic arthritis. L. monocytogenes is not
September 11-13, 2014 - Utrecht - The Netherlands
137
Abstracts Posters
generally considered to be a causative agent of osteo-articular infections. We report the first case of spondylodiscitis
due to L. monocytogenes.
Case description: In January 2014, a 92 year-old man was
admitted to the emergency unit at Nantes University hospital for fever and acute low back pain for one week associated with an inflammatory syndrome and oliguria. His medical history included arterial hypertension, heart failure and
arrhythmia, gastric ulcer and hip arthroplasty. On admission, he had a temperature of 38.2°C and paraspinal muscle
spasm. Blood tests showed a total white cell count of 7.47
G.L-1 (normal range, 4-10 G.L-1) with 82.7% neutrophils,
raised C-reactive protein (CRP) level of 190.8 mg.L-1 (normal
range, < 5 mg.L-1) and normal renal function test. Magnetic
resonance imaging of the lumbar spine revealed abnormal
contrast enhancement in the posterior aspect of the L3–L4,
L4-L5 and L5-S1 discs and end-plate with surrounding soft
tissue and epidural enhancement. Three aerobic and anaerobic blood cultures were performed on the peripheral site
over the course of 24 h. The two first aerobic blood cultures
yielded Gram-positive bacilli after 22 h of incubation. After
24h of incubation, this bacterium was hemolytic on blood
agar, with rapid positive esculine test. In the mean time, a
fast identification was performed by mass spectrometry (Vitek MS, bioMérieux) leading to an identification to L. monocytogenes. In vitro susceptibility testing revealed a fully
susceptible bacterium to a wide range of antibiotics: amoxicillin, levofloxacin, moxifloxacin, aminoglycosides, tetracycline, lincomycin, cotrimoxazole, and rifampin, according
to the European Committee on Antimicrobial Susceptibility
Testing (EUCAST) guidelines. Consequently, antibiotic therapy with intravenous amoxicillin (16g daily) during six days
and gentamicin (480 mg daily) during four days was started
and then switched for cotrimoxazole (800 mg 3 times daily)
during three months. Two months later, the patient recovered slowly and regained mobility. Investigation to identify
the source of infection found in the fridge raw milk and raw
milk cheese but cultures remained negative.
Discussion: To the best of our knowledge, this is the first report of spondylodiscitis due to L. monocytogenes. Mass spectrometry technology allows an accurate and rapid bacterial
identification. Therefore, the antibiotic treatment could have
been adapted 24h after sampling. Microbiologists and physicians should be aware when, in light of Gram’s stain result,
L. monocytogenes may or should be suspected, especially in
elderly and/or immunocompromised patients.
P50
138
Hyperbaric oxygen therapy as a part of treatment of anaerobic spondylodiscitis after
vertebroplasty: a case report
Miha Vodičar, Lovro Suhodolčan, Rok Vengust, Robert Košak
Department Of Orthopedic Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
Aim: To report a case of Clostridium perfringens anaerobic
spondylodiscitis following vertebroplasty, treated with abscess puncture, antibiotic and hyperbaric oxygen therapy
(HBOT).
Methods: The 59 years old male presented 1 week after
vertebroplasty at L1 and L2 levels with intensive back pain
and loss of motor deficit in proximal muscles of the right
leg with elevated CRP, WBC and ESR. MRI with gadolinium
contrast revealed spondylodiscitis at the Th12-L1, L1-L2 and
L2-L3 levels with paravertebral abscess. CT guided puncture
of abscess was performed and Clostridium perfringens was
isolated. Targeting antibiotic therapy was administered and
the patient was subjected to hyperbaric oxygen therapy
with 100% O2 at 2.4 atmospheres absolute (ATA) for 90 minutes twice daily for 5 consecutive days.
Results: Patient’s clinical status gradually returned to normal. He was discharged after 33 days of intravenous antibiotic therapy, and remained asymptomatic until the 1-year
follow up.
Conclusions: Percutaneous vertebroplasty is a standard
procedure in the treatment of painful osteoporotic compression fractures of the vertebra. The procedure is gener-
ally accepted as safe, although serious complications have
been reported. Only 11 cases of post-operative spondylitis
or spondylodiscitis have been reported in the literature. All
authors report of primary conservative treatment, whereas
in cases of failure operative treatment with debridment,
corpectomy, bone grafting and posterior stabilization was
employed. In our case therapy had several parts: CT guided drainage, intravenous antibiotics, hyperbaric chamber
oxygenation, analgesics, and immobilization. Most infectious tissues are hypoxic because of ischemia secondary to
inflammation – induced tissue edema; therefore adequate
delivery of oxygen to the wound tissues is vital for the healing process and for resistance to infection. Our experience
suggests that addition of HBOT to the percutaneous CT
guided abscess drainage and targeting antibiotic therapy
contributes to the favorable outcome of anaerobic spondylodiscitis.
References
1. Kutlay M. Undersea Hyperb Med 2008;35:427-40.
2. Schofer MD. J Med Case Rep 2011;5:101.
3. Alfonso Olmos M. Spine 2006;31:E770-3.
33rd Annual Meeting of the European Bone & Joint Infection Society
Abstracts Posters
P53
Debridement and prosthesis retention in early enterococcus faecalis/faecium infection
Stijn Duijf 1, Jon Goosen 1, Fidel Vos 1, Jacques F. Meis2
1
Sint Maartenskliniek, Nijmegen, Netherlands
2
Radboud UMC, Catherina-Wilhelmina Ziekenhuis, Nijmegen, Netherlands
Introduction: Periprosthetic joint infections (PJI) with Enterococcus faecalis and faecium are difficult to treat and are
associated with a high rate of failure of the prosthesis after
early infection.
The aim of this study was to assess outcome after treatment
for early PJI with an identified causative Enterococcus after
a follow-up of two years.
Methods: Patients with primary or revision total knee (TKA)
or total hip (THA) arthroplasty, a minimum of one periprosthetic tissue culture positive for Enterococcus faecalis/faecium and minimal follow-up of 140 days were retrospectively
included in this study. All patients were treated using a similar treatment protocol, i.e. debridement and retention of the
prosthesis, followed by a twelve weeks adequate antibiotic
regime. Patients’ hospital records were reviewed and we evaluated the status of the original prosthesis after an infection.
Results: Forty-six cases were included (17 knees and 29 hips)
with a mean follow-up of 760 days (150-1642 days) after final
infection treatment. Open debridement was performed at a
mean of 16 days after the primary procedure in all patients.
Debridement was performed a mean of two times in each
patient. During follow-up in the knee arthroplasty cases 8 patients underwent revision surgery or ended up with an amputation, which was considered a failure of early treatment.
At final follow-up 9 out of 17 TKAs and 20 out of 29 THAs were
in situ and showed no clinical signs of infection. In total 17 patients warranted a two stage revision or amputation because
of persisting signs of infection (8 TKAs and 9 THAs).
Conclusion: In case of early infection with Enterococcus
faecalis/faecium open debridement and retention of the
prosthesis should be performed followed by adequate and
long-term (three months) antibiotic treatment.
Although the prognosis after PJI with Enterococcus is still
relatively poor, our study shows promising results when
made use of adequate antibiotic treatment.
Acknowledgements
We have no conflicts of interest to declare.
139
P54
Oral levofloxacin plus rifampicin as first choice for the treatment of anterior cruciate ligament
infections
Daniel Pérez-Prieto1, Andrej Trampuz2, Raul Torres1, Juan Pablo Horcajada1, María Eugenia Portillo3, Lluís Puig-Verdié1, Joan
Carles Monllau1
1
Parc De Salut Mar, Barcelona, Spain
2
Charité, Berlín, Germany
3
Laboratori De Referència De Catalunya, Barcelona, Spain
Introduction and Aim: Recent reports on Anterior Cruciate Ligament (ACL) acute infections [Saper,2014, AbdelAziz,2013] have concluded that retention and arthroscopic
débridement in patients with stable graft should be the preferred choice. Nevertheless, there is no reported data for the
best antibiotic treatment option and its duration. The aim of
the study was to assess the efficacy of oral levofloxacin and
rifampicin for the treatment of ACL acute infections
Methods: 810 patients operated on for ACL reconstruction
in a 3 years period were retrospectively reviewed. It was
considered infection when C-reactive protein (CRP) was elevated, pus was observed or cultures were positive. Fourteen
(1.7%) out of 810 were therefore considered as infection (Table-1). In all cases a joint aspiration was obtained. Then an
arthroscopic lavage was performed as soon as possible and
tissue samples were taken. Then empiric iv antibiotic was
started until the cultures results were available. Minimum
follow-up of 2 years was considered to establish the infection as healed along with negative CRP, correct function and
a pain-free knee.
Results: Among the 12 staphilococcal cases (86%), 9 were
susceptible to both quinolones and rifampicin (75% of the
staphilococccal infections). In 2 cases the microorganisms
were rifampicin resistant. In one additional case the CNS
was resistant to quinolones. Alternative antibiotic treatment
in those resistant cases could be seen in Table 1. It is of remarkable interest that one of the quinolones and rifampicin
susceptible CNS was treated with linezolid and rifampicin.
This was the only case in which the graft had to be removed
due to treatment failure. In the remaining 11 patients CRP
levels returned to normality in a mean of 3 weeks without
local symptoms. Function and pain improved, although
these patients never reached functional scores as patients
without infection. Antibiotic treatment had a median dura-
September 11-13, 2014 - Utrecht - The Netherlands
Abstracts Posters
tion of 6 weeks and orally treatment started in a mean of 5
days (range 4-7).
Conclusions: Similar to previous studies [Maletis,2013, Zalavras,2005] Staphilococci (especially CNS) are the responsible of almost 90% of acute ACL infections. Early switch to
oral therapy makes discharge possible in few days without
CASE
ACL graft
1
2
Hamstring
Hamstring
3
Patellar tendon
4*
5
6
7
8
9
10
11
12
13
14
Hamstring
Hamstring
Patellar tendon
Hamstring
Hamstring
Hamstring
Hamstring
Hamstring
Hamstring
Hamstring
Hamstring
Levofloxacin + Rifampicin
Levofloxacin + Rifampicin
0.4
0.6
Number of
arthroscopic
lavages
1
2
Amoxiciline + Clavulanic Acid
0.5
1
6
Linezolid + Rifampicin
Levofloxacin + Rifampicin
Cotrimoxazol + Rifampicin
Levofloxacin + Rifampicin
Ciprofloxacin + Rifampcin
Ciprofloxacin
Amoxiciline + Clavulanic Acid
Levofloxacin + Rifampicin
Levofloxacin + Rifampicin
Levofloxacin + Rifampicin
Levofloxacin
0.2
0.2
0.2
0.2
0.9
0.9
0.2
0.6
0.5
0.2
0.2
3
1
2
2
1
1
1
1
1
1
1
6
6
6
5
6
4
6
6
6
6
6
Micro-organism
S. aureus
MRSA
Propionibacterium
acnes
CNS
CNS
CNS
CNS
CNS
S. aureus
Unknown
CNS
CNS
CNS
CNS
all hospital risks and costs. Additionally, although here is
presented just one case of linezolid failure, it should be considered with caution because of it only provides a bacteriostatic effect. Therefore, early oral antibiotic treatment with
levofloxacin and rifampicin for 6 weeks should be considered as first choice in acute staphilococccal ACL infections.
Antibiotic
CRP** at end
follow-up
Antibiotic therapy
duration (weeks)
8
6
* Patient who required graft removal. ** CRP: C Reactive Protein (mg/dl)
CNS: Coagulase negative staphylococci
Anterior Cruciate Ligament (ACL) infection treatment.
140
P55
WITHDRAWN
P56
Is vancomycin-loaded dac hydrogel coating of orthopedic implants safe for human use?
Short-term clinical results in two european centers
Konstantinos Malizos1, Polykarpos Kiorpelidis1, Delia Romano2, Andrea Peccati2, Lorenzo Drago3, Carlo Luca Romano4
University Hospital Of Larissa & Cereteth, Larissa, Greece
2
Centro Di Chirurgia Ricostruttiva E Delle Infezioni Osteo-Articolari, IRCCS Galeazzi, Milano, Italy
3
Laboratorio Analisi Cliniche E Microbiologiche - ISTITUTO IRCCS Galeazzi, Milano, Italy
4
Istituto Ortopedico Irccs Galeazzi, Milano, Italy
1
Aim: Infection remains a leading reason for failure of orthopaedic implants. Among various strategies, aimed at
implant-related infection prevention, antibacterial coatings
appear an attractive and effective option to prevent bacterial colonization of biomaterials. A fast resorbable (<96 h),
antibacterial-loaded hydrogel coating (DAC, Novagenit Srl,
Italy), previously tested successfully in vitro and in vivo (13), is currently available for clinical use in Europe. Aim of
this study was to evaluate the short-term clinical safety of
a vancomycin-loaded DAC implant coating in orthopaedics.
Methods: In this prospective, single blind study, a total of 58
patients, undergoing total hip or knee prosthesis or osteosynthesis were randomly assigned to receive vancomycinloaded DAC coating or to a control group, without coating.
Pre- and post-operative assessment of laboratory tests,
wound healing (ASEPSIS score), clinical score and x-rays was
performed at fixed time intervals. Statistical analysis was
performed with Fisher exact test or Student’s t test. Significance level was set at p<0.05.
Results: Wound healing, clinical outcome scores, laboratory
33rd Annual Meeting of the European Bone & Joint Infection Society
Abstracts Posters
tests and radiographic findings did not show any significant
difference between the two-groups at a mean 6 months follow-up (min: 3, max: 12 months). No early infections of the
surgical site were observed in either group and no local or
systemic side effects, that could be related to DAC hydrogel
coating, were noted.
Conclusion: Vancomycin-loaded DAC hydrogel coating
appears clinically safe in this first randomised clinical trial
evaluating short-term outcome.
The study was performed under the multicenter Collaborative Project “I.D.A.C.”, funded by the European Commission,
within the 7th Framework Programme on Research Technological Development and Demonstration, grant no. 277988.
References:
Cementless hip prosthesis cup coating with vancomycin-loaded
DAC hydrogel
1.Romanò CL, Giammona G, Giardino R, Meani E (2011) Antibioticloaded resorbable hydrogel coating for infection prophylaxis of orthopaedics implants: preliminary studies. J Bone Joint Surg Br 2011
93-B: 337-338.
2.Giavaresi G, Meani E, Sartori M, Ferrari A, Bellini D, Sacchetta AC,
Meraner J, Sambri A, Vocale C, Sambri V, Fini M, Romanò CL. (2013) Efficacy of antibacterial-loaded coating in an in vivo model of acutely
highly contaminated implant. Int Orthop. 2013 Dec 22.
3. Drago L., Boot W, Dimas K, Malizos K, Hänsch GM, Stuyck J, Gawlitta
D, Romanò CL. (2014) Does implant coating with antibacterial-loaded hydrogel reduce bacterial colonization and biofilm formation in
vitro ? Clin Orthop Relat Res DOI 10.1007/s11999-014-3558-1.
P57
Debridement and prosthesis retention in early Pseudomonas aeruginosa infection
Ewout Veltman1, Jacques Meis2, Fidel Vos3, Jon Goosen
1
St. Maartenskliniek Nijmegen, Nijmegen, Netherlands
2
Canisius-Wilhelmina Ziekenhuis, Nijmegen, Netherlands
3
Radboud University Medical Center, Nijmegen, Netherlands
Introduction: Periprosthetic joint infection (PJI) can have
devastating effects on patients’ quality of life.(1;2) Infections
with Pseudomonas aeruginosa (PA) are difficult to treat and
are associated with limited success.(3;4)
The aim of this study was to assess outcome after treatment
for early PJI (<3 months after the index operation) with PA.
Methods: Patients with primary or revision total joint arthroplasty, a minimum of two periprosthetic tissue cultures
positive for PA and minimal follow-up of one year were retrospectively included in this study. All patients were treated
using a similar treatment protocol. Postoperative antibiotic
treatment consisted of 12 weeks ciprofloxacin following the
final surgical intervention. Patients’ hospital records were
reviewed and we evaluated the amount of adverse events
at follow-up.
Results: We included twelve cases of early PJI with PA after
a mean follow-up of 39 months after final infection treatment. Open debridement was performed at a mean of 14
days after the primary procedure in all patients. Debridement was performed a mean of two times in each patient.
During follow-up two patients warranted a two-stage revision of the prosthesis, which was considered a failure of
early treatment. Ten out of twelve patients retained the
original prosthesis after open debridement and antibiotic
treatment.
141
Of patients who failed treatment, one is using ciprofloxacin
for persisting infection. The other patient has currently no
complaints and no signs of infection in laboratory findings.
Conclusion: In case of early infection with PA open debridement and retention of the prosthesis should be performed
followed by adequate and long-term (three months) antibiotic treatment with ciprofloxacin. In contrast with current
literature, our study shows good results after open debridement for PA PJI.
Acknowledgements
We have no conflicts of interest to declare.
Reference List
(1) Zmistowski B, Karam JA, Durinka JB, Casper DS, Parvizi J. Periprosthetic joint infection increases the risk of one-year mortality. J Bone
Joint Surg Am 2013 Dec 18;95(24):2177-84.
(2) Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N
Engl J Med 2004 Oct 14;351(16):1645-54.
(3) Hsieh PH, Lee MS, Hsu KY, Chang YH, Shih HN, Ueng SW. Gram-negative prosthetic joint infections: risk factors and outcome of treatment. Clin Infect Dis 2009 Oct 1;49(7):1036-43.
(4) Zmistowski B, Fedorka CJ, Sheehan E, Deirmengian G, Austin MS,
Parvizi J. Prosthetic joint infection caused by gram-negative organisms. J Arthroplasty 2011 Sep;26(6 Suppl):104-8.
September 11-13, 2014 - Utrecht - The Netherlands
Abstracts Posters
P58
WITHDRAWN
P59
WITHDRAWN
P60
Surgical tactics for the treatment of the purulent septic complications after endoprosthetics
of the large joints
Vladimir Obolenskiy1, Pulad Leval2, Stanislav Golev2, Alexander Ermolov3, Magomad Magomadov4
City Hospital 13, RNRMU, Moscow, Russia
2
City Hospital 13, Moscow, Russia
3
RNRMU, City Hospital 13, Moscow, Russia
4
Rufp, Moscow, Russia
1
142
Aim: To assess the efficiency of the local negative pressure
wound therapy (NPWT) and revision spacer*) endoprosthetics (RSE) for the treatment of the purulent septic complications (PSC) after large joints endoprosthetics (EP).
Methods: The analysis of the treatment outcomes of 133
patients with PSC after large joints EP (the hip 82 and knee
51, age from 19 to 91 (63.2±1.1), 44 males, 89 females) - was
performed. The time from the initial operation to the development of PSC was from 3 days to 17 years. There were 58
type 1 (Coventry-Fitzgerald-Tsukayama), 43 type 2, 32 type
3; 35 infections of the area of the surgical intervention (IASI),
98 deep infections (DI).
Results: For 19 patients with DI related to EP NPWT was
applied, followed by the wound suturing: 6 experienced
relapse within 4 months; 13 remained relapse-free within
6-24 months of the follow-up period. For 5 patients with IASI
related to EP NPWT was applied, followed by the wound su-
turing: all remained relapse-free within 6-24 months of the
follow-up period. All the patients with DI and 6 patients
with IASI without NPWT experienced relapse of PSC.
In 55 patients implant removal was performed; in 8 cases,
draining-washing system was left (7 relapse-free from 4
months to 4 years); in 5 cases a collagen sponge, impregnated with an antibiotic**), were inserted into the bone canal and acetabulum leading to relapse-free period duration
4-24 months; 42 patients underwent RSE: in 4 cases - the
dislocation of the spacer, in 1 patient - fracture of the leg of a
spacer, in 1 case - recurrence of osteomyelitis; the remaining
36 patients without PSC in time 3-48 month.
Conclusion: The using of NPWT and RSE allows to improve
the treatment results of the PSC after large joints EP.
*) Biomet
**) Collatamp EG
P61
Treatment of acute periprosthetic infections with retention of the prosthesis, a current
concepts review
Sascha Colen1, Jesse Kuiper2, Robin Theenk Willink1, Dirk Moojen3, Michel van den Bekerom3
University Hospitals Leuven, Department Of Orthopaedic Surgery, Leuven, Belgium
2
Center For Orthopaedic Research Alkmaar (CORAL), Medical Center Alkmaar, Alkmaar, Netherlands
3
Onze Lieve Vrouwe Gasthuis, Department Of Orthopaedic Surgery And Traumatology, Amsterdam, Netherlands
1
Aim: Periprosthetic joint infection (PJI) is a devastating complication after total joint arthroplasty, occurring in approximately 1-2% of all cases. With growing populations and increasing age, PJI will have a growing effect on health care
costs. Many risk factors have been identified that increase
the risk of developing PJI, including obesity, immune system deficiencies, malignancy, previous surgery of the same
joint and longer operating time. In this review we will discuss the evidence based treamtent options for acute PJIs
Results: Acute PJI occurs either postoperatively (4 weeks to
33rd Annual Meeting of the European Bone & Joint Infection Society
Abstracts Posters
3 months after initial arthroplasty, depending on the classification system), or via hematogenous spreading after a
period in which the prosthesis had functioned properly.
Diagnosis and the choice of treatment are the cornerstones
to success. Although different definitions for PJI have been
used in the past, most are more or less similar and include
the presence of a sinus tract, blood infection values, synovial white blood cell count, signs of infection on histopathological analysis and one or more positive culture results. Debridement, antibiotics and implant retention (DAIR) is the
primary treatment for acute PJI, and should be performed
as soon as possible after the development of symptoms.
Success rates differ, but most studies report success rates
of around 60-80%. Whether single or multiple debridement procedures are more successful remains unclear. The
use of local antibiotics in addition to the administration of
systemic antibiotic agents is also subject to debate, and its
pro’s and con’s should be carefully considered. Systemic
treatment, based on culture results, is of importance for all
PJI treatments, and should be maintained for three months
for acute hip PJI. Additionally, rifampin should be given in
Staphylococcal PJIs, unless all foreign material is removed.
The most important factors contributing to treatment failure are longer duration of symptoms, a longer time after
initial arthroplasty, the need for more debridement procedures, the retention of exchangeable components, and PJI
caused by Staphylococcus (aureus or coagulase negative).
If DAIR treatment is unsuccessful, the following treatment
option should be based on the patient health status and
his or her expectations. For the best functional outcome,
one- or two-stage revision should be performed after DAIR
failure.
Conclusions: DAIR is the obvious choice for treatment of
acute PJI, with good success rates in selected patients.
P62
Megaprosthesis in septic bone defects
Tomas Mut Oltra, Jose Baeza Oliete, Manuel Angulo Sanchez ,Jose Amaya, Francisco Baixauli Garcia
Hospital La Fe, Valencia, Spain
Aim: Massive bone loss of the upper and lower limb and
the relative joints is a complex problem. The use of new
megaprosthesis for massive bone loss is an option for the
replacement of skeletal segments. There are several clinical situations that can be associated with this problem, including severe trauma with multiple failed osteosynthesis,
with a non union or a previous prosthetic replacement of a
neighbouring joint, multiple revision of arthroplasty with or
without infection or large resection of tumours. The aim of
this work is to eveluate the cases treated with a mega prosthesis in our hospital from February 2012 to January 2014.
Methods: We performed a retrospective review of 15 patients treated with megaprosthesis from February 2012 to
January 2014, subdivided as follows:
7 distal femur
4 proximal femur
2 total femur
1 proximal humerus and
1total humerus.
The aetology was 6 septic non unions, 3 infected TKA, 4 infected THA and 2 cronic osteomyelitis.
The mean age of the patients was 56 years old (range 32-80)
7 patients were female and 8 male. Clinical and serial radiographic evaluations were performed. Blood parameters including CRP and ESR were monitorized.
Results: Although the mean of follow-up was only 15.53
months, the results show encouraging clinical results.We
described the complications associated,the surgical techniques and the perioperative procedure.Success was defined by both: the absence of symptoms of infection local or
general as well as blood parameters.
Conclusion: Megaprosthesis provides a valuable opportunity to restore functionally to patients with highly disabling
diseases.
September 11-13, 2014 - Utrecht - The Netherlands
143
Abstracts Posters
P63
An unusual case of Salmonella typhimurium and mrsa co-infection of a prosthetic hip joint:
double trouble and a narrow squeak!
Deepa Nayar, Suresh Thomas, Patrick Duffy
County Durham And Darlington Foundation Trust, Durham, United Kingdom
144
Aim: Salmonella infections of prosthetic joints are rare.
There are only a handful of cases reported in literature. We
report an unusual case of a 78 year old man with a dual infection with Salmonella typhimurium and MRSA.
Case Presentation: This 78 year old man had undergone
bilateral primary total hip replacements (THR) 8 years ago.
Past medical history included previous CABG, Type 1 DM
and recurrent urinary tract infections.
He presented in April 2012 with a unilateral thigh collection,
which was incised and drained. Pus from drainage grew Salmonella typhimurium. There was no evidence of the collection communicating with the THR on that side.
With the unusual nature of the organism, detailed history
taking and look back revealed that he had suffered from
S.typhimurium gastroenteritis in September 2011 after a
holiday abroad. Whilst symptomatic with diarrhoea, he had
suffered a fall on his hip and had developed a hematoma.
Typing of the strains from pus and faeces revealed the organism to be identical.
He was treated with 6 weeks of IV Tazocin.
He represented in September 2012 with a draining sinus.
Microbiology cultures revealed the same S. typhimurium
but also an MRSA.
After several investigations (ECHO, Renal, Liver and abdomen imaging) to rule out another deep-seated source, he
underwent a 2 stage revision, with a tailor made antibiotic
impregnated cement and antibiotic impregnated calcium
sulfate beads and systemic antibiotics. He was treated in
the interval phase with Ciprofloxacin and Teicoplanin for 6
weeks and also postoperatively after second stage. For local
delivery, we used Vancomycin and Gentamicin at first stage
both in cement and in Calcium sulphate 1 beads. At second
stage, we added Vancomycin and Meropenem to Calcium
sulphate beads and to cement.
Follow up at 14 months indicates he is symptom free with a
well-functioning prosthesis.
Learning Points: Despite infection with a rare microbe, two
stage revision with carefully planned antimicrobial cover
including effective local delivery of antibiotics can lead to
successful outcome. This challenging case highlights the
need for careful planning and multi-disciplinary team working between Orthopedic surgeons and infection specialists
as key for success.
References
1. Stimulan R , Biocomposites Ltd, Keele Science Park, Staffordshire, UK
P64
Negative pressure wound therapy and intra-articular antibiotics instillation (npwtiai) a novel
alternative approach in chronic pji management?
Kordo Saeed1, Matthew Dryden2
1
Hampshire Hospitals Nhs Foundation Trust, Southampton University Medical School, Winchester, United Kingdom
2
Hampshire Hospitals Nhs Foundation Trust, Winchester, United Kingdom
Aims: Whilst a minority of arthroplasties will become infected, the incidence of prosthetic joint infection (PJI) is likely
to increase over the coming years, a major burden for patients and hospitals. Debridement and implant retention is
not widely considered for chronic PJI due to lower success
rates. We describe a novel strategy using Negative-PressureWound-Therapy with intra-articular-antibiotic-instillation
(NPWTiai)# system as an alternative approach in chronic PJI
management.
The system produces Negative-Pressure-Wound-Therapy while
automatically delivering “topical-solutions#” to the wound site,
allowing even distribution of fluid and suction with enhanced
granulation tissue formation [1]. We used NPWTiai in three patients with chronic PJI, our aims were to cure the infection and
retain the implant in one; and to cure the infection and acceler-
ate healing in the remaining two cases.
Methodology:
1. Initial Debridement
2. NPWTiai daily cycles#
* Instillation-phase (fluid volume depends on wound size)
* Hold-phase (20 minutes)
* VACUME-phase (100 minutes at-125mmHg))
* Replace dressing (72-96 hourly)
3. Review instillation fluid volume as wound size gets smaller
4. Review need for instillation-phase
5. Review need for VACUME-phase
6. Review need to close wound
Results: 1) Chronic hip PJI re-revisions and long-term antibiotics with break-through infections. A clinical management
plan was agreed between patient and clinicians to undergo
33rd Annual Meeting of the European Bone & Joint Infection Society
Abstracts Posters
further surgical debridement followed by NPWTiai aiming
to eradicate the infection and implant retention. Following
debridement and positive culture of Pseudomonas aeruginosa, the patient received three weeks of IV Pipracillin/
Tazobactam and three weeks of intra-articular Gentamicin.
This was followed by only 3 weeks of oral Ciprofloxacin. The
implant successfully retained for 2 years without further PJI.
2) Chronic hip PJI re-infections with Staphylococcus aureus
despite 8 surgical debridement and implant removal. NPWTiai therapy with intra-articular Vancomycin for 3 weeks and
systemic Flucloxacillin for 6 weeks resulted in resolution of
infection and wound healing.
3) Chronic hip PJI with mixed coliforms and eneterococci.
NPWT was successfully used with intra-articular antiseptic§
to accelerate healing and cure.
Conclusions: Above successful cases suggest that NPWTiai could be used as an alternative approach in managing
chronic PJI, especially where implant retention is intended
or unavoidable. Further studies are needed to address the
efficacy and its cost effectiveness.
References
1. Lessing C et al. Clinical Symposium on Advances in Skin and Wound
Care 2010 Orlando, Florida
6. Saeed K et al. Tech Orthop 2013;28:201–206
# VAC-ULTA/VeraFlo™ KCI Medical, Ltd, antibiotics are not licensed with
this system
§ Prontosan®
P65
A rare case report of extensive foot osteomyelitis by Corynebacterium striatum following
penetrating injury
Brijesh Ayyaswamy, Ramankutty Sreekumar, Achyut Guleri
Blackpool Victoria Hospital, Blackpool, United Kingdom
Introduction: Corynebacterium subspecies has been reported to cause osteomyelitis inimmunocompromised
patients.They are normal commensals in skin and mucous
membrane and are considered to be opportunistic pathogens. There is no report of extensive foot osteomyelitis in
healthy patient with this bacterium. This rare case is being
reported due to the extensive nature of infection caused by
this organism in healthy young adult and relative lack of inflammation for such an infection.
Methods: A 27 year old male sustained a penetrating injury
in the sole of foot .He developed cellulitis and was given Flucloxacillin by GP for 3 weeks. He presented with cellulitis.
He was given IV Clindamycin and later changedto Ceftriaxone. Ultrasound was done and it did not show any deepseated abscess. A week later he developed a subcutaneous abscess which was drained.His blood parameters were
normal at initial presentation and throughout the course of
treatment(wbc-8.3nuetrophil-6.18 and CRP-2).His cellulitis
improved and was discharged from ward. His culturedid not
grow any organism.
Results: He came back with recurrent cellulitis and discharging wound and was put on Clarithromycin.Due to recurrent
cellulitis MRI was performed and it showed extensive osteomyelitis of cuboid,cuneiforms with 3rd,4th and 5th metatarsal base involvement with subcutaneous oedema He was
taken to theatre and debrided again and sent the tissue for
culture and sensitivity. The culture grew Corynebacterium
striatum. By this time he could not tolerate most of the
antibiotic and he was having vomiting and diarrhoea with
most of the sensitive antibiotics. Microbiologist decided to
start him on Linezolid and he was tolerating it.His cellulitis
resolved completely and his osteomyelitis subsided.He had
Linezolid for 6 weeks .There is no recurrence at 7 months
follow and repeat MRI showed complete clearance of infection.
Conclusions: Corynebacterium can cause extensive infection without causing much inflammation andshould be
considered for any acute foot and ankle infection especially
after foreign body injury.
September 11-13, 2014 - Utrecht - The Netherlands
145
Abstracts Posters
P66
WITHDRAWN
P67
Prosthetic joint and fracture-fixation device infections: a guidance diagnostic protocol from
the italian association of clinical microbiologists (amcli)
Iole Caola1, Francesco Tessarolo2, Mario Sarti3, Marco Conte4, Eleonora Zamparini5, Pierluigi Viale5, Carlo Romanò6, Lorenzo Drago7
Microbiology And Virology Division, Azienda Provinciale Per I Servizi Sanitari Di Trento, Trento, Italy
2
IRCS Project, Bruno Kessler Foundation & Dept Of Industrial Engineering, University Of Trento, Trento, Italy
3
Provincial Laboratory Of Clinical Microbiology, NOCSAE Baggiovara, Modena, Italy
4
Microbiology And Virology Division, Ospedali Dei Colli, Napoli, Italy
5
Clinic Of Infectious Diseases,University Of Bologna, Bologna, Italy
6
Department Of Reconstructive Surgery Of Osteo-Articular Infections, IRCCS Galeazzi Orthopaedic Institute, Milano, Italy
7
Laboratory Of Clinical Chemistry And Microbiology, IRCCS Galeazzi Orthopaedic Institute, Milano, Italy
1
146
Introduction and Aim: Prosthetic joint infection (PJI) is a serious complication in orthopaedic surgery and requires an
accurate microbiological diagnosis to ensure an adequate
clinical management. The definition of PJI has not yet found
a total consensus. A key role in the diagnosis is still played
by microbiological investigations, contributing to the identification of infected cases and allowing the isolation and
identification of the microorganisms responsible for infection and its antibiotic sensitivity. The Italian Association
of Clinical Microbiologists (AMCLI) has recently released a
guidance protocol for the diagnostic workup of PJI and fracture-fixation device infections (FFDI) in the microbiology
laboratory. An overview of the AMCLI guidance and some
insight into the proposed protocols will be presented.
Methods: Literature findings were integrated with the clinical experience coming from the major Italian orthopaedic
centres for identifying pre-analytical and analytical procedures, as well as interpretative criteria for laboratory results.
Protocols focused on number and type of pre-operative and
intra-operative samples for obtaining optimal sensitivity
and specificity. Sampling methods were identified according to clinical and laboratory requirements. Different procedural options were described for culturing articular fluid
and prosthetic components in order to fit different microbiology laboratory settings and equipment availability.
Results: Sampling, transportation, and preservation methods are detailed for articular fluid, perimplantar tissue,
prosthetic components and fracture-fixation devices. Pro-
cedures and techniques for preventing sample contamination and cross-contamination are recommended. Minimal
requirements for laboratory instrumentations are presented
according to proposed protocols. Cultural methods for articular fluid include enrichment in liquid medium or direct
inoculation in blood culture bottles. A minimum number of
three tissue biopsies should be sampled from representative periprosthetic areas and cultures should include tissue
homogenization, plating on solid media and broth enrichment. Biofilm dislodgment from removed prosthetic components and fracture-fixation devices is proposed by using
sonication or elution with lytic solution. Incubation time is
specified according to sample type and cultural method. Interpretative criteria are proposed for both quantitative and
qualitative cultural results. Reporting of laboratory results is
addressed in order to support the clinical diagnosis.
Conclusions: AMCLI guidance propose a state of art protocol for treatment of PJI and FFDI samples, supporting the
microbiologist in data interpretation and reporting. To provide an effective support to the diagnosis of PJI and FFDI,
multiple samples should be provided to the microbiology
laboratory. Specific equipment and procedures are needed
according to different sample types. Moreover, a synergic
approach among the orthopaedic surgeon, the infectious
disease specialist and the microbiologist allow to increases
significantly the probability of diagnosing and eradicating
the infection.
33rd Annual Meeting of the European Bone & Joint Infection Society
Abstracts Posters
P68
Posterior percutaneous instrumentation as a safe and effective treatment for pyogenic
spondylodiscitis in a patient with severe non-improving pain; a case report
Elias Papadopoulos1, Helen Giamarellou2, Lambrini Galani2, Elias Karaiskos2, Fotini Baziaka2, George Babis 1
University Of Athens, School Of Medicine, Athens, Greece
2
Hygeia Hospital, Athens, Greece
1
Aim: To present a case of posterior percutaneous spinal
instrumentation for single-level pyogenic spondylodiscitis
and discuss the safety and effectiveness of this method.
Methods: Treatment of pyogenic spondylodiscitis (PS) is
based on intravenous antibiotics and rigid brace immobilization (TLSO). Operative treatment in the form of posterior
spinal instrumentation (PSI) is only considered in patients
with neurological deterioration, in severe kyphotic deformity and in cases uncontrolled infection or pain. In the present
case, a 54 year old man was admitted to our hospital with a
1-week history of acute back pain and normal neurological
exam. Labs and imaging studies showed L2-3 spondylodiscitis, and a CT-guided biopsy isolated community acquired
methicillin resistant Staphylococcus aureus (CA-MRSA). Intravenous treatment was administered (levofloxacin and
trimethoprim/sulfamethoxazole); four weeks later and despite the improvement of the laboratory tests, patient failed
to show pain improvement and remained bedbound. He
subsequent underwent percutaneous PSI (L1-L4).
Results: One week after the operation patient was sedentary
and independent of pain medication. He was discharged on
p.o. Levofloxacin and trimethoprim/ sulfamethoxazole. Patient was seen in the clinic at 1, 3, 6, and 9 months, and ESR,
CRP, complete blood count, VAS were obtained. Complete
infection healing was achieved and no changes were observed in segmental pre- and post-treatment kyphosis. No
instrumentation-related complications were observed.
Conclusion: Posterior percutaneous spinal instrumentation
is a safe, feasible, and effective procedure in relieving pain,
preventing deformity, and neurologic compromise in patients affected by noncomplicated PS. In this case, surgical
stabilization was associated with faster recovery, lower pain
scores, and improved quality of life.
147
Image depictive of minimal violation of the spinal soft tissue
envelope
P69
WITHDRAWN
September 11-13, 2014 - Utrecht - The Netherlands
Abstracts Posters
P70
Linezolid therapy in a perinatal late-onset Staphylococcus aureus sepsis complicated by
spondilodiscitis and endophtalmitis
Andrzej Krzysztofiak1, Elena Bozzola1, Elena Bellelli1, Guido La Rosa2, Gaetano Pagnotta2, Laura Lancella1, Alberto Villani1
1
Pediatric And Infectiuos Disease Unit, Pediatric Dep. Bambino Gesù Hospital, Rome, Rome, Italy
2
Orthopedic Unit, Bambino Gesù Hospital, Rome, Rome, Italy
148
Staphylococcus aureus remains a major pathogen causing
invasive life-threatening bacterial infections in neonates
such as bacteraemia, septic shock and osteomyelitis. Most
of the concurrent infections in mother-infant occur in the
first two weeks after delivery, with symptoms onset between 7 and 12 days of age. Paediatric spondylodiscitis is
an uncommon infection, complicating 1% to 2% of osteomyelitis in children. Staphylococcus aureus is the most common cause of osteomyelitis in all age groups, on account of
its peculiar tropism for bone tissue.
We report a two months immunocompetent female child
affected by Staphylococcus aureus sepsis complicated with
pneumonia and pleural effusion, spondylodiscitis and endophthalmitis treated with linezolid. She developed a Staphylococcus aureus sepsis in the neonatal period antibiotically
treated with clinical resolution. Ten days after therapy discontinuation, the infant experienced a new Staphylococcus aureus sepsis complicated by pneumonia with pleural
effusion. For the presence of dorsal swelling, a pulmonary
computer tomography was performed that showed a dorsal
D5-D6 spondylodiscitis. The sepsis was scarcely responsive
to several and appropriate antibiotics, so that we finally decided to treat the patient with linezolid. A few weeks after
antibiotic change, the child underwent an ophthalmologic
visit. Due to the finding of ocular lesions, imaging examinations were performed. The diagnosis was compatible with
retinoblastoma, so that the eye was enucleated. Nevertheless, histological and microbiological investigations did not
confirm the tumour hypothesis, but revealed a Staphylococcus aureus abscess with retinal detachment. The child completed the antibiotic therapy with linezolid and was visited
periodically at Infectious Disease Unit for follow-up. She
underwent progressive resolution of discitis and did not
present any more flare of sepsis. Nevertheless she still has
a replacement device at her right eye and a D5-D6 severe
kyphosis with spinal fusion.
Neonatal Staphylococcus aureus sepsis is a life threatening
condition which may be severely complicated by hematogenous spread of the infection to several organs and tissues.
Spondylodiscitis as well as EBE must be promptly recognised in order to avoid bone squeals and preserve vision.
Linezolid appears to be effective and safe in the treatment
of paediatric patients with severe infection for its approved
and off-label indications, including pneumonia and spondylodiscitis. Nevertheless, the potential for haematological
toxicity of linezolid in children means that careful monitoring is required during treatment.
33rd Annual Meeting of the European Bone & Joint Infection Society