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Objectives: The combination of a fluoroquinolone with rifampin is one of the cornerstones in the treatment of prosthetic joint infections (PJI) caused by staphylococci. Moxifloxacin is highly active against methicillin-susceptible Staphylococcus aureus (MSSA) and, therefore, is an attractive agent to use. However, several studies reported a lowering in serum moxifloxacin levels when combined with rifampin. The clinical relevance remains unclear. We determined the outcome of patients with early acute PJI caused by MSSA treated with either moxifloxacin/rifampin or levofloxacin/rifampin., Methods: Medical files of patients treated with moxifloxacin/rifampin (University Medical Centre Groningen) or levofloxacin/rifampin (Hospital Clinic Barcelona) were retrospectively reviewed (2005-2015). Treatment failure was defined as the need for revision surgery and/or suppressive therapy, death by infection or a relapse of infection during follow-up., Results: Differences in baseline characteristics between the two cohorts were observed, but prognostic parameters for failure, as defined by the KLIC-score (Kidney failure, Liver cirrhosis, Index surgery, C-reactive protein and Cemented prosthesis), were similar in the two groups (2.9 [1.5 SD] for the moxifloxacin group vs. 2.2 [1.2 SD] for the levofloxacin group [P = 0.16]). With a mean follow-up of 50 months (36 SD) in the moxifloxacin group, and 67 months (50 SD) in the levofloxacin group (P = 0.36), treatment was successful in 89% vs. 87.5%, respectively (P = 0.89). None of the failures in the moxifloxacin group were due to rifampin- or moxifloxacin-resistant S. aureus strains., Conclusion: Our data indicate that moxifloxacin combined with rifampin is as clinically effective as levofloxacin/rifampin for early acute PJI caused by MSSA., (Copyright © 2017 Elsevier B.V. and International Society of Chemotherapy. All rights reserved.)

Background: Surgical site infection (SSI) rate after surgery for hip fracture is about 4%. The aim of the present study was to review the efficacy of dual prophylaxis using teicoplanin plus cefuroxime and risk factors for SSI., Patients: Operations for hip fracture from 2012 to 2013 were retrospectively reviewed. Relevant information was gathered: Demographics, comorbidities, ASA score, laterality, type of fracture, type of surgery, d from admission to surgery, length of surgery, hemoglobin value at admission, urinary or respiratory infections, and the need for pre-operative, intra-operative, and post-operative red blood cell (RBC) transfusion. Prophylaxis consisted of cefuroxime and teicoplanin during the induction of anesthesia. U.S. Centers for Disease Control and Prevention (CDC) criteria for superficial and deep SSI were applied. Univariate and multivariable analysis were performed., Results: Six hundred fifty-seven patients were included in the study. Thirteen (2.0%) SSI were identified, six superficial (0.9%), and seven deep (1.1%). Staphylococcus aureus was isolated in two infections (one superficial and one deep). The SSI rate was 2.4% in intra-medullary nails (n = 334), 1.4% in prostheses (n = 211), and 1.8% in other synthesis (n = 112). Parameters independently associated with SSI were: Intra-operative RBC transfusion (OR: 11.6, p = 0.002), length of surgery >120 min (OR: 4.5, p = 0.02), and having a urinary infection (OR: 4.28, p = 0.02)., Conclusion: Dual prophylaxis including cefuroxime and teicoplanin was associated with a 2% rate of SSI. Staphylococcus aureus caused only two SSIs. Reducing SSI is of utmost importance for patients' quality of life and to avoid additional cost of surgical procedures. Therefore, more experience with dual prophylaxis is needed to confirm our results.

Objectives: To compare the specific characteristics, the outcome and the predictors of failure of prosthetic joint infections (PJI) due to methicillin-resistant (MRS) and methicillin- susceptible staphylococci (MSS) treated with open debridement and retention of the implant., Material and Methods: PJI due to MRS or MRS prospectively registered in a database from 1999 to 2009 were retrospectively reviewed., Results: During the study period, 96 patients met the inclusion criteria of the study. The mean follow-up period was 3.9 years and at least 2 years in all patients. The failure rate was 25%. The only variable significantly associated with failure in the global cohort was polymicrobial infection (59.3% vs. 40.7%, p=0.036). Thirty-four (35.4%) patients had an infection due to MRS and 62 (63.6%) due to MSS. Among MSS infections, 95.2% corresponded to primary arthroplasties while 29.4% of PJI due to MRS were after revision arthroplasties (p=0.001). CRP was significantly higher in PJI due to MSS (5.2 mg/dl vs 9.1 mg/dL, p=0.02).The failure rate (20% vs 27%, p=0.62) was very similar in MSS and MRS groups., Conclusion: PJI due to MRS were mainly coagulase-negative staphylococci, more frequent after revision arthroplasties, had a lower inflammatory response, and had a similar failure rate than MSS infections.

Introduction: The aim of our study was to compare the effectiveness of high-pressure pulsatile lavage and low-pressure lavage in patients with an orthopaedic implant infection treated with open débridement followed by antibiotic treatment., Patients and Methods: Patients with an orthopaedic implant infection requiring open débridement from January 2008 to August 2009 were randomized prospectively to a low-pressure or a high-pressure pulsatile lavage arm. Relevant information about demographics, co-morbidity, type of implant, microbiology data, surgical treatment, and outcome were recorded. Comparison of proportions was made using χ(2) test or Fisher exact test when necessary. The Kaplan-Meier survival method was used to estimate the cumulative probability of treatment failure from open débridement to the last visit., Results: Seventy-nine patients were included. There were no differences between the main characteristics between both groups (p > 0.05). Mean (SD) age of the whole cohort was 70.2 (11.9) years. There were 46 infections on knee prosthesis, 17 on hip prosthesis, 7 on hip hemiarthroplasties and 9 on osteosynthesis devices. There were 69 acute post-surgical infections, 8 acute haematogenous infections and 2 chronic infections. The most common microorganisms isolated were coagulase-negative Staphylococci in 34 cases, Staphylococcus aureus in 26 and Escherichia coli in 19 cases. There were 30 polymicrobial infections. A total of 42 and 37 patients were randomized to a high-pressure pulsatile or a low-pressure lavage, respectively. There was no difference in the success rate between both arms (80.9 vs. 86.5%, p = 0.56)., Conclusion: The use of a high-pressure pulsatile lavage during open débridement of implant infections had a similar success rate as a low-pressure lavage.

Purposes: To review patients with a hematogenous and early post-surgical prosthetic joint infection (PJI) due to S. aureus treated with debridement and retention of the implant and to compare their clinical characteristics and outcome., Methods: From January 2000 all patients with a prosthetic joint infection treated in a single-center were prospectively registered and followed-up. All potentially variables associated with outcome were recorded. For the present study, cases with a hematogenous or early post-surgical PJI due to S. aureus treated with debridement and at least 2 years of follow-up were reviewed. Cox regression model to identify factors associated with outcome were applied., Results: 12 hematogenous and 53 early post-surgical PJI due to S. aureus were included. Number of patients presenting with fever, leucocyte count, C-reactive protein concentration, and the number of bacteremic patients were significantly higher in hematogenous infections while the number of polymicrobial infections was lower in hematogenous than in early post-surgical infections. The global failure rate in hematogenous and early post-surgical PJI was 58.7% and 24.5%, respectively (p=0.02). The Cox regression model identified hematogenous infections (OR: 2.57, CI95%: 1.02-6.51, p=0.04) and the need of a second debridement (OR: 4.61, CI95%: 1.86-11.4, p=0.001) as independent predictors of failure., Conclusion: Hematogenous infections were monomicrobial and had more severe symptoms and signs of infection than early post-surgical PJI. Hematogenous PJI due to S. aureus, using debridement with implant retention, had a worse outcome than early post-surgical infections.

Experience with debridement and prosthesis retention in early prosthetic joint infections (PJI) due to Staphylococcus aureus is scarce. The present study aimed to evaluate the outcome and predictors of failure. Patients prospectively registered with an early PJI due to S. aureus and 2 years of follow-up were reviewed. Demographics, co-morbidity, type of implant, clinical manifestations, surgical treatment, antimicrobial therapy and outcome were recorded. Remission was defined when the patient had no symptoms of infection, the prosthesis was retained and C-reactive protein (CRP) was ≤ 1 mg/dL. Univariate and multivariate analysis were performed. Fifty-three patients with a mean ± SD age of 70 ± 10.8 years were reviewed. Thirty-five infections were on knee prosthesis and 18 were on hip prosthesis. The mean ± SD duration of intravenous and oral antibiotics was 10.6 ± 6.7 and 88 ± 45.9 days, respectively. After 2 years of follow-up, 40 (75.5%) patients were in remission. Variables independently associated with failure were the need for a second debridement (OR 20.4, 95% CI 2.3-166.6, p 0.006) and a CRP > 22 mg/dL (OR 9.8, 95% CI 1.5-62.5, p 0.01). The onset of the infection within the 25 days after joint arthroplasty was at the limit of significance (OR 8.3, 95% CI 0.8-85.6, p 0.07). Debridement followed by a short period of antibiotics is a reasonable treatment option in early PJI due to S. aureus. Predictors of failure were the need for a second debridement to control the infection a CRP > 22 mg/dL and the infection onset within the first 25 days after joint arthroplasty., (© 2010 The Authors. Journal Compilation © 2010 European Society of Clinical Microbiology and Infectious Diseases.)

Introduction: The histology of periprosthetic tissue is a gold standard for the diagnosis of periprosthetic joint infection. However, the specificity and sensitivity of histology has never been 100%. In the present study we hypothesized that the type of microorganism could be related to the effectiveness of histology in the detection of infection., Material and Methods: Frozen sections and cultures from periprosthetic tissue of 38 revision arthroplasties taken at the time of resection arthroplasty for the treatment of infection were retrospectively reviewed. Frozen sections were evaluated following Feldman's criteria. A culture was considered positive when the same microorganism was isolated in at least two samples or when pus was present around the prosthesis. The literature providing information on histology and microbiology of arthroplasty-associated infection was reviewed., Results: Coagulase-negative staphylococcus (CNS) was the etiology in 13 cases, Gram-negative bacilli in 8, Staphylococcus aureus in 7, Candida sp in 2, Peptococcus sp in 2, Enterococcus sp in 1 and S. pneumoniae in 1. No microorganism was isolated in four cases. Almost all the frozen sections in the 38 cases were positive except in 2 of the 13 that were caused by CNS (15.3%). The articles reviewed supported our findings., Conclusion: Frozen section is a useful test to intraoperatively confirm an infection when preoperative septic loosening is suspected. However, histology has false-negative results when the infection is due to low-virulence microorganisms.

Aim: To evaluate the usefulness of (99m)Tc-Sulphur colloid when combined with leukocyte scintigraphy in suspected prosthetic hip infection, comparing the results with information from (99m)Tc-HMPAO-leukocyte scintigraphy alone., Materials and Methods: Seventy patients (42 women, 28 men; mean age 68 +/- 13 years) with painful hip prostheses and suspicion of infection were evaluated prospectively. All patients had bone scintigraphy, (99m)Tc-HMPAO-labelled white blood cell scintigraphy and (99m)Tc-Sulphur colloid bone marrow scintigraphy. ESR and CRP levels were measured in all patients. The final diagnosis was made with microbiological findings or by clinical follow up of at least 12 months., Results: Infections were diagnosed in 12 of the 70 patients (3 coagulase-negative Staphylococcus, 2 Staphylococcus aureus, 2 Staphylococcus epidermidis, 2 enterococcus and 3 polymicrobial agents). ESR and CRP values were higher in patients with infection than in patients without infection (51.8 +/- 29.4 vs. 25.4 +/- 16.4 and 2.8 +/- 2.2 vs. 1.1 +/- 1.3, respectively; p < 0.05). Bone scintigraphy did not show a characteristic pattern to differentiate infection from aseptic loosening. The pool phase of the bone scintigraphy was positive in only 3/12 patients with infection (25 %). Sensitivity and specificity of the leukocyte scintigraphy was 83 % and 57 %, respectively. When the results of the bone marrow scintigraphy were added, these values increased to 92 % and 98 %, respectively., Conclusion: Performing bone marrow scintigraphy significantly improves results when compared with leukocyte scintigraphy alone in the diagnosis of infected hip prostheses. Bone scintigraphy did not help to differentiate aseptic loosening from infection in this series.

In order to gather more data on the use of teicoplanin for reducing MRSA infections in high-risk populations, the present study was conducted. At a hospital in Barcelona, Spain, there was a high prevalence of MRSA infections among patients who underwent surgery for femoral neck fracture during the first 5 months of 2002 (period A) when cefuroxime was the antibiotic prophylaxis. During the following 12 months (period B) 600 mg of teicoplanin was added to cefuroxime. The rates of overall and MRSA infection during period A were 5.07 and 2.73%, respectively. Pulsed-field gel electrophoresis demonstrated there was no clonal relationship among MRSA strains. No nasal carriers of MRSA were detected among health workers. During period B the rates of overall and MRSA infection were 2.36 and 0.19%, respectively. Both rates were statistically significantly lower than those in period A (p<0.05). These results suggest teicoplanin may be useful in patients undergoing orthopedic surgery when the prevalence of MRSA is high.