Providing an Evidence Base for Tissue Sampling and Culture Interpretation in Suspected Fracture-Related Infection.
Journal
The Journal of bone and joint surgery. American volume
ISSN: 1535-1386
Titre abrégé: J Bone Joint Surg Am
Pays: United States
ID NLM: 0014030
Informations de publication
Date de publication:
02 06 2021
02 06 2021
Historique:
pubmed:
26
3
2021
medline:
9
11
2021
entrez:
25
3
2021
Statut:
ppublish
Résumé
The recent consensus definition for the diagnosis of fracture-related infection (FRI) includes the identification of indistinguishable microorganisms in at least 2 surgical deep-tissue specimens as a confirmatory criterion. However, this cut-off, and the total number of specimens from a patient with suspected FRI that should be sent for microbiological testing, have not been validated. We endeavored to estimate the accuracy of different numbers of specimens and diagnostic cut-offs for microbiological testing of deep-tissue specimens in patients undergoing surgical treatment for possible FRI. A total of 513 surgical procedures in 385 patients with suspected FRI were included. A minimum of 2 surgical deep-tissue specimens were submitted for microbiological testing; 5 or more specimens were analyzed in 345 procedures (67%). FRI was defined by the presence of any confirmatory criteria other than microbiology. Resampling was utilized to model the sensitivity and specificity of diagnostic cut-offs for the number of surgical specimens yielding indistinguishable microorganisms and for the total number of specimens. The likelihood of detecting all clinically relevant microorganisms was also assessed. A diagnostic cut-off of at least 2 of 5 specimens with indistinguishable microorganisms identified by culture was 68% sensitive (95% confidence interval [CI], 62% to 74%) and 87% specific (95% CI, 81% to 94%) for the diagnosis of FRI. Two out of 3 specimens were 60% sensitive (95% CI, 55% to 66%) and 92% specific (95% CI, 88% to 96%). Submitting only 3 deep-tissue specimens risked missing clinically relevant microorganisms in at least 1 in 10 cases. The present study was the first to validate microbiological criteria for the diagnosis of FRI, supporting the current confirmatory diagnostic criteria for FRI. Analysis of at least 5 deep-tissue specimens in patients with possible FRI is recommended. Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Sections du résumé
BACKGROUND
The recent consensus definition for the diagnosis of fracture-related infection (FRI) includes the identification of indistinguishable microorganisms in at least 2 surgical deep-tissue specimens as a confirmatory criterion. However, this cut-off, and the total number of specimens from a patient with suspected FRI that should be sent for microbiological testing, have not been validated. We endeavored to estimate the accuracy of different numbers of specimens and diagnostic cut-offs for microbiological testing of deep-tissue specimens in patients undergoing surgical treatment for possible FRI.
METHODS
A total of 513 surgical procedures in 385 patients with suspected FRI were included. A minimum of 2 surgical deep-tissue specimens were submitted for microbiological testing; 5 or more specimens were analyzed in 345 procedures (67%). FRI was defined by the presence of any confirmatory criteria other than microbiology. Resampling was utilized to model the sensitivity and specificity of diagnostic cut-offs for the number of surgical specimens yielding indistinguishable microorganisms and for the total number of specimens. The likelihood of detecting all clinically relevant microorganisms was also assessed.
RESULTS
A diagnostic cut-off of at least 2 of 5 specimens with indistinguishable microorganisms identified by culture was 68% sensitive (95% confidence interval [CI], 62% to 74%) and 87% specific (95% CI, 81% to 94%) for the diagnosis of FRI. Two out of 3 specimens were 60% sensitive (95% CI, 55% to 66%) and 92% specific (95% CI, 88% to 96%). Submitting only 3 deep-tissue specimens risked missing clinically relevant microorganisms in at least 1 in 10 cases.
CONCLUSIONS
The present study was the first to validate microbiological criteria for the diagnosis of FRI, supporting the current confirmatory diagnostic criteria for FRI. Analysis of at least 5 deep-tissue specimens in patients with possible FRI is recommended.
LEVEL OF EVIDENCE
Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Identifiants
pubmed: 33764925
doi: 10.2106/JBJS.20.00409
pii: 00004623-202106020-00005
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
977-983Commentaires et corrections
Type : CommentIn
Type : ErratumIn
Informations de copyright
Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.
Déclaration de conflit d'intérêts
Disclosure: The authors indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJS/G423).
Références
Morgenstern M, Kühl R, Eckardt H, Acklin Y, Stanic B, Garcia M, Baumhoer D, Metsemakers WJ. Diagnostic challenges and future perspectives in fracture-related infection. Injury. 2018 Jun;49(Suppl 1):S83-90.
Trampuz A, Zimmerli W. Diagnosis and treatment of infections associated with fracture-fixation devices. Injury. 2006 May;37(Suppl 2):S59-66.
Lerner RK, Esterhai JL Jr, Polomano RC, Cheatle MD, Heppenstall RB. Quality of life assessment of patients with posttraumatic fracture nonunion, chronic refractory osteomyelitis, and lower-extremity amputation. Clin Orthop Relat Res. 1993 Oct;295:28-36.
Metsemakers WJ, Morgenstern M, McNally MA, Moriarty TF, McFadyen I, Scarborough M, Athanasou NA, Ochsner PE, Kuehl R, Raschke M, Borens O, Xie Z, Velkes S, Hungerer S, Kates SL, Zalavras C, Giannoudis PV, Richards RG, Verhofstad MHJ. Fracture-related infection: a consensus on definition from an international expert group. Injury. 2018 Mar;49(3):505-10. Epub 2017 Aug 24.
Gristina AG, Costerton JW. Bacterial adherence to biomaterials and tissue. The significance of its role in clinical sepsis. J Bone Joint Surg Am. 1985 Feb;67(2):264-73.
Simpson AHRW, Wood MK, Athanasou NA. Histological assessment of the presence or absence of infection in fracture non-union. Injury. 2002 Mar;33(2):151-5.
Schmidt AH, Swiontkowski MF. Pathophysiology of infections after internal fixation of fractures. J Am Acad Orthop Surg. 2000 Sep-Oct;8(5):285-91.
Ochsner PE, Hailemariam S. Histology of osteosynthesis associated bone infection. Injury. 2006 May;37(Suppl 2):S49-58.
Zuluaga AF, Galvis W, Saldarriaga JG, Agudelo M, Salazar BE, Vesga O. Etiologic diagnosis of chronic osteomyelitis: a prospective study. Arch Intern Med. 2006 Jan 9;166(1):95-100.
Hackl S, Hellinger L, Von Rüden C, Friedrichs J, Bühren V, Perl M, Hierholzer C. Low-grade infection in the pathogenesis of primarily aseptically classified nonunion of the lower extremity: based on tibial shaft nonunion. Orthop Proc. 2018;98-B(Supp.23):13.
Morgenstern M, Athanasou NA, Ferguson JY, Metsemakers WJ, Atkins BL, McNally MA. The value of quantitative histology in the diagnosis of fracture-related infection. Bone Joint J. 2018 Jul;100-B(7):966-72.
Govaert GAM, Kuehl R, Atkins BL, Trampuz A, Morgenstern M, Obremskey WT, Verhofstad MHJ, McNally MA, Metsemakers WJ; Fracture-Related Infection (FRI) Consensus Group. Diagnosing fracture-related infections: current concepts and recommendations. J Orthop Trauma. 2020 Jan;34(1):8-17.
Dudareva M, Barrett L, Figtree M, Scarborough M, Watanabe M, Newnham R, Wallis R, Oakley S, Kendrick B, Stubbs D, McNally MA, Bejon P, Atkins BA, Taylor A, Brent AJ. Sonication versus tissue sampling for diagnosis of prosthetic joint and other orthopaedic device-related infections. J Clin Microbiol. 2018 Nov 27;56(12):1-12.
Dudareva M, Hotchen AJ, Ferguson J, Hodgson S, Scarborough M, Atkins BL, McNally MA. The microbiology of chronic osteomyelitis: changes over ten years. J Infect. 2019 Sep;79(3):189-98. Epub 2019 Jul 15.
Hellebrekers P, Rentenaar RJ, McNally MA, Hietbrink F, Houwert RM, Leenen LPH, Govaert GAM. Getting it right first time: the importance of a structured tissue sampling protocol for diagnosing fracture-related infections. Injury. 2019 Oct;50(10):1649-55. Epub 2019 Jun 7.
Efron B, Tibshirani RJ. An introduction to the bootstrap. Chapman & Hall/CRC; 1993.
R Core Team. R: a language and environment for statistical computing. R Foundation for Statistical Computing; 2017. https://www.R-project.org/
RStudio Team. RStudio: integrated development for R. RStudio, Inc.; 2016. http://www.rstudio.com/
Bémer P, Léger J, Tandé D, Plouzeau C, Valentin AS, Jolivet-Gougeon A, Lemarié C, Kempf M, Héry-Arnaud G, Bret L, Juvin ME, Giraudeau B, Corvec S, Burucoa C; Centre de Référence des Infections Ostéo-articulaires du Grand Ouest (CRIOGO) Study Team. How many samples and how many culture media to diagnose a prosthetic joint infection: a clinical and microbiological prospective multicenter study. J Clin Microbiol. 2016 Feb;54(2):385-91. Epub 2015 Dec 4.
Al-Mayahi M, Cian A, Lipsky BA, Suvà D, Müller C, Landelle C, Miozzari HH, Uçkay I. Administration of antibiotic agents before intraoperative sampling in orthopedic infections alters culture results. J Infect. 2015 Nov;71(5):518-25. Epub 2015 Aug 15.
Yano MH, Klautau GB, da Silva CB, Nigro S, Avanzi O, Mercadante MT, Salles MJ. Improved diagnosis of infection associated with osteosynthesis by use of sonication of fracture fixation implants. J Clin Microbiol. 2014 Dec;52(12):4176-82. Epub 2014 Sep 17.