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Enterococcal periprosthetic joint infection: clinical and microbiological findings from a 8-year retrospective cohort study
Andrej Trampuz
Charite Universitatsmedizin Berlin
Corresponding Author
ORCiD: https://orcid.org/0000-0002-5219-2521
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This work is licensed under a CC BY 4.0 License. Read Full License
View the published version at BMC Infectious Diseases.
Background: Treatment of enterococcal periprosthetic joint infections (PJI) is challenging due to non-standardized management strategies and lack of biofilm-active antibiotics. The optimal surgical and antimicrobial therapy are unknown. Therefore, we evaluated characteristics and outcome of enterococcal PJI. Methods: Consecutive patients with enterococcal PJI from two specialized orthopedic institutions were retrospectively analyzed. Both institutions are following the same diagnostic and treatment concepts. The probability of relapse-free survival was estimated using Kaplan-Meier survival curves and compared by log-rank test. Treatment success was defined by absence of relapse or persistence of PJI due to enterococci or death related to enterococcal PJI. Clinical success was defined by the infection-free status, no subsequent surgical intervention for persistent or perioperative infection after re-implantation and no PJI-related death within 3 months. Results: Included were 75 enterococcal PJI episodes, involving 41 hip, 30 knee, 2 elbow and 2 shoulder prostheses. PJI occurred postoperatively in 61 episodes (81%), hematogenously in 13 (17%) and by contiguous spread in one. E. faecalis grew in 64 episodes, E. faecium in 10 and E. casseliflavus in one. Additional microorganism(s) were isolated in 38 patients (51%). Enterococci were susceptible to vancomycin in 73 of 75 isolates (97%), daptomycin in all 75 isolates, and fosfomycin in 21 of 22 isolates (96%). The outcome data was available for 66 patients (88%). The treatment success after 3 years was 83.7% (95% confidence interval [CI]; 76.1-96.7%) and the clinical success was 67.5% (95% CI; 57.3-80.8%). In 11 patients (17%), a new PJI episode caused by a different pathogen occurred. All failures occurred within the three years of surgery. Conclusion: About half of enterococcal PJI were polymicrobial infections. The treatment success was high (84%). All treatment failures occurred within the first three years after revision surgery. Interestingly, 17% of patients experienced a new PJI caused by another pathogen at a later stage. Trial registration: The study was retrospectively registered with the public clinical trial identification NCT0253022 at https://www.clinicaltrials.gov on 15 July 2015.
Keywords
Periprosthetic joint infection, Enterococcus spp., Outcome, Microbiology, Biofilm
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On 27 Dec, 2019
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Reviewers invited
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Reviewers invited
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On 22 Oct, 2019
Editor assigned
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Submission checks complete
On 14 Oct, 2019
Editor invited
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On 20 Sep, 2019
Review #2 received
Received 16 Sep, 2019
Review #1 received
Received 15 Sep, 2019
Reviewer #2 agreed
On 03 Sep, 2019
Reviewer #1 agreed
On 01 Sep, 2019
Reviewers invited
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Submission checks complete
On 08 Aug, 2019
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On 08 Aug, 2019
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This preprint is under consideration at BMC Infectious Diseases. A preprint is a preliminary version of a manuscript that has not completed peer review at a journal. Research Square does not conduct peer review prior to posting preprints. The posting of a preprint on this server should not be interpreted as an endorsement of its validity or suitability for dissemination as established information or for guiding clinical practice.
Learn more about In Review
Research article
Enterococcal periprosthetic joint infection: clinical and microbiological findings from a 8-year retrospective cohort study
Andrej Trampuz
Charite Universitatsmedizin Berlin
Corresponding Author
ORCiD: https://orcid.org/0000-0002-5219-2521
Badges
Prescreen
This manuscript passed our Prescreen assessment
Complete author information
Appropriate declaration statements
Potential risks to human health
Prescreen
Peer Review Timeline
CURRENT STATUS: Published
Version 4
Posted 18 Dec, 2019
Published
On 27 Dec, 2019
No community comments so far
Submission checks complete
On 05 Dec, 2019
Editorial decision: Accept
On 05 Dec, 2019
Editor assigned
On 04 Dec, 2019
Editor invited
On 03 Dec, 2019
Editorial decision: Minor revision
On 23 Nov, 2019
No comments provided
Reviewers invited
Invitations sent on 18 Nov, 2019
Reviewer #1 agreed
On 18 Nov, 2019
Review #1 received
Received 18 Nov, 2019
Editor assigned
On 13 Nov, 2019
Submission checks complete
On 12 Nov, 2019
Editor invited
On 12 Nov, 2019
No comments provided
Editorial decision: Minor revision
On 08 Nov, 2019
Review #2 received
Received 04 Nov, 2019
Review #1 received
Received 25 Oct, 2019
Reviewer #2 agreed
On 23 Oct, 2019
Reviewers invited
Invitations sent on 22 Oct, 2019
Reviewer #1 agreed
On 22 Oct, 2019
Editor assigned
On 15 Oct, 2019
Submission checks complete
On 14 Oct, 2019
Editor invited
On 14 Oct, 2019
No comments provided
Editorial decision: Major revision
On 20 Sep, 2019
Review #2 received
Received 16 Sep, 2019
Review #1 received
Received 15 Sep, 2019
Reviewer #2 agreed
On 03 Sep, 2019
Reviewer #1 agreed
On 01 Sep, 2019
Reviewers invited
Invitations sent on 18 Aug, 2019
Submission checks complete
On 08 Aug, 2019
Editor assigned
On 08 Aug, 2019
Editor invited
On 07 Aug, 2019
First submitted
On 04 Aug, 2019
Metrics
Comments: 0
PDF Downloads: ...
HTML Views: ...
Subject Areas
Infectious Diseases
License:
This work is licensed under a CC BY 4.0 License. Read Full License
View the published version at BMC Infectious Diseases.
Background: Treatment of enterococcal periprosthetic joint infections (PJI) is challenging due to non-standardized management strategies and lack of biofilm-active antibiotics. The optimal surgical and antimicrobial therapy are unknown. Therefore, we evaluated characteristics and outcome of enterococcal PJI. Methods: Consecutive patients with enterococcal PJI from two specialized orthopedic institutions were retrospectively analyzed. Both institutions are following the same diagnostic and treatment concepts. The probability of relapse-free survival was estimated using Kaplan-Meier survival curves and compared by log-rank test. Treatment success was defined by absence of relapse or persistence of PJI due to enterococci or death related to enterococcal PJI. Clinical success was defined by the infection-free status, no subsequent surgical intervention for persistent or perioperative infection after re-implantation and no PJI-related death within 3 months. Results: Included were 75 enterococcal PJI episodes, involving 41 hip, 30 knee, 2 elbow and 2 shoulder prostheses. PJI occurred postoperatively in 61 episodes (81%), hematogenously in 13 (17%) and by contiguous spread in one. E. faecalis grew in 64 episodes, E. faecium in 10 and E. casseliflavus in one. Additional microorganism(s) were isolated in 38 patients (51%). Enterococci were susceptible to vancomycin in 73 of 75 isolates (97%), daptomycin in all 75 isolates, and fosfomycin in 21 of 22 isolates (96%). The outcome data was available for 66 patients (88%). The treatment success after 3 years was 83.7% (95% confidence interval [CI]; 76.1-96.7%) and the clinical success was 67.5% (95% CI; 57.3-80.8%). In 11 patients (17%), a new PJI episode caused by a different pathogen occurred. All failures occurred within the three years of surgery. Conclusion: About half of enterococcal PJI were polymicrobial infections. The treatment success was high (84%). All treatment failures occurred within the first three years after revision surgery. Interestingly, 17% of patients experienced a new PJI caused by another pathogen at a later stage. Trial registration: The study was retrospectively registered with the public clinical trial identification NCT0253022 at https://www.clinicaltrials.gov on 15 July 2015.
Figure 1
Figure 2
Figure 3
Figure 4