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Background: Fluoroquinolones (FQs) are known to be accompanied by significant risks. However, the incidence of adverse events (ADEs) resulting in unplanned drug discontinuation when used for periprosthetic joint infections (PJIs) is currently unknown., Methods: This study included 156 patients over the age of 18 treated for staphylococcal PJI with debridement, antibiotics, and implant retention between 1 January 2007 and 21 November 2019. Of the 156 patients, 64 had total hip arthroplasty (THA) and 92 had total knee arthroplasty (TKA) infections. The primary outcome was rate of unplanned drug discontinuation. Secondary outcomes included incidence of severe ADEs, unplanned rifamycin discontinuation, mean time to unplanned regimen discontinuation, and all-cause mortality., Results: Overall, unplanned drug discontinuation occurred in 35.6% of patients in the FQ group and 3% of patients in the non-FQ group. The rate of unplanned discontinuation of FQ regimens as compared with non-FQ regimens was 27.5% vs 4.2% (P = .021) in THA infections and 42% vs 2.4% (P < .001) in TKA infections. There was no significant difference in severe ADEs between FQ and non-FQ regimens in both THA and TKA infections. The overall rate of nonsevere ADEs in FQ compared with non-FQ regimens was 43.3% vs 6.1% (P < .001). FQs were associated with tendinopathy, myalgia, arthralgia, and nausea., Conclusions: A significantly higher rate of unplanned drug discontinuation was associated with FQ as compared with non-FQ regimens. This provides a real-world view of the implications of FQ-related ADEs on unplanned discontinuation when used in prolonged durations for the management of staphylococcal PJIs., (© The Author(s) 2021. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

In this cohort of 51 patients managed with retained "destination spacers" after the resection of infected joint prostheses, the presence of preoperative sinus drainage was significantly associated with reinfection. Chronic antimicrobial suppression after destination-spacer retention did not significantly prevent reinfections., (© The Author(s) 2019. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Defining the microbial etiology of culture-negative prosthetic joint infection (PJI) can be challenging. Metagenomic shotgun sequencing is a new tool to identify organisms undetected by conventional methods. We present a case where metagenomics was used to identify Mycoplasma salivarium as a novel PJI pathogen in a patient with hypogammaglobulinemia., (© The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

These guidelines are intended for use by infectious disease specialists, orthopedic surgeons, neurosurgeons, radiologists, and other healthcare professionals who care for patients with native vertebral osteomyelitis (NVO). They include evidence and opinion-based recommendations for the diagnosis and management of patients with NVO treated with antimicrobial therapy, with or without surgical intervention., (© The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.)

These guidelines are intended for use by infectious disease specialists, orthopedic surgeons, neurosurgeons, radiologists, and other healthcare professionals who care for patients with native vertebral osteomyelitis (NVO). They include evidence and opinion-based recommendations for the diagnosis and management of patients with NVO treated with antimicrobial therapy, with or without surgical intervention., (© The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.)

These guidelines are intended for use by infectious disease specialists, orthopedists, and other healthcare professionals who care for patients with prosthetic joint infection (PJI). They include evidence-based and opinion-based recommendations for the diagnosis and management of patients with PJI treated with debridement and retention of the prosthesis, resection arthroplasty with or without subsequent staged reimplantation, 1-stage reimplantation, and amputation.

These guidelines are intended for use by infectious disease specialists, orthopedists, and other healthcare professionals who care for patients with prosthetic joint infection (PJI). They include evidence-based and opinion-based recommendations for the diagnosis and management of patients with PJI treated with debridement and retention of the prosthesis, resection arthroplasty with or without subsequent staged reimplantation, 1-stage reimplantation, and amputation.

Background: The actual risk of prosthetic joint infection as a result of dental procedures and the role of antibiotic prophylaxis have not been defined., Methods: To examine the association between dental procedures with or without antibiotic prophylaxis and prosthetic hip or knee infection, a prospective, single-center, case-control study for the period 2001-2006 was performed at a 1200-bed tertiary care hospital in Rochester, Minnesota. Case patients were patients hospitalized with total hip or knee infection. Control subjects were patients who underwent a total hip or knee arthroplasty but without a prosthetic joint infection who were hospitalized during the same period on the same orthopedic floor. Data regarding demographic features and potential risk factors were collected. Logistic regression was used to assess the association of variables with the odds of infection., Results: A total of 339 case patients and 339 control subjects were enrolled in the study. There was no increased risk of prosthetic hip or knee infection for patients undergoing a high-risk or low-risk dental procedure who were not administered antibiotic prophylaxis (adjusted odds ratio [OR], 0.8; 95% confidence interval [CI], 0.4-1.6), compared with the risk for patients not undergoing a dental procedure (adjusted OR, 0.6; 95% CI, 0.4-1.1) respectively. Antibiotic prophylaxis in high-risk or low-risk dental procedures did not decrease the risk of subsequent total hip or knee infection (adjusted OR, 0.9 [95% CI, 0.5-1.6] and 1.2 [95% CI, 0.7-2.2], respectively)., Conclusions: Dental procedures were not risk factors for subsequent total hip or knee infection. The use of antibiotic prophylaxis prior to dental procedures did not decrease the risk of subsequent total hip or knee infection.

Background: The optimal medical or surgical therapy and outcome of enterococcal prosthetic joint infection are unknown., Method: We performed a retrospective cohort study involving all patients with enterococcal total hip or knee arthroplasty infection treated at our institution from 1969 through 1999. The outcome for patients treated with combination systemic antimicrobial therapy (a cell wall-active agent and an aminoglycoside) versus monotherapy with a cell wall-active agent was analyzed., Results: Fifty episodes of prosthetic joint infection due to enterococci occurred in 47 patients. The median duration of follow-up was 1253 days (range, 29-4610 days). The median age at the time of diagnosis was 70 years (range, 32-89 years). Fifty percent of episodes (25 of 50 episodes) occurred in male patients; 48% (24 of 50 episodes) involved total hip or knee arthroplasty. The estimate of 2-year survival free of treatment failure was 94% (95% confidence interval [CI], 83%-100%) for patients treated with 2-stage exchange, 76% (95% CI, 58%-100%) for patients treated with resection arthroplasty, and 80% (95% CI, 51.6%-100%) for patients treated with debridement and retention of the components (P=.9). The overall rate of 2-year survival free of treatment failure was 88% (95% CI, 77%-100%) for patients treated with monotherapy and 72% (95% CI, 54%-96%) for patients treated with combination therapy (P=.1). The development of cranial nerve VIII toxicity was significantly more common among patients receiving combination therapy (P=.002). Nephrotoxicity was more frequent in the combination therapy group (occurring in 26% of episodes; P=.09)., Conclusions: Enterococcal prosthetic joint infection is uncommon at our institution. Patients receiving combination therapy and those receiving monotherapy did not differ with respect to outcome. There were more cases of ototoxicity in the combination therapy group than there were in the monotherapy group.

Background: Culture-negative (CN) prosthetic joint infection (PJI) has not been well studied. We performed a retrospective cohort study to define the demographic characteristics and determine the outcome of patients with CN PJI., Methods: All cases of CN total hip arthroplasty and total knee arthroplasty infections (using a strict case definition) treated at our institution from January 1990 through December 1999 were analyzed. Kaplan-Meier survival methods were used to determine the cumulative probability of success., Results: Of 897 episodes of PJI during the study period, 60 (7%) occurred in patients for whom this was the initial episode of CN PJI. The median age of the cohort was 69 years (range, 36-87 years). Patients had received a prior course of antimicrobial therapy in 32 (53%) of 60 episodes. Of the 60 episodes, 34 (57%), 12 (20%), and 8 (13%) were treated with 2-stage exchange, debridement and retention, and permanent resection arthroplasty, respectively. The median duration of parenteral antimicrobial therapy was 28 days (range, 0-88 days). Forty-nine (82%) of 60 episodes were treated with a cephalosporin. The 5-year estimate of survival free of treatment failure was 94% (95% confidence interval, 85%-100%) for patients treated with 2-stage exchange and 71% (95% confidence interval, 44%-100%) for patients treated with debridement and retention., Conclusions: CN PJI occurs infrequently at our institution. Prior use of antimicrobial therapy is common among patients with CN PJI. CN PJI treated at our institution is associated with a rate of favorable outcome that is comparable to that associated with PJI due to known bacterial pathogens.

Background: Prosthetic joint infection (PJI) due to rapidly growing mycobacteria (RGM) is only occasionally encountered in clinical practice. Therefore, the optimal clinical management for this condition is unknown., Methods: The medical records of patients who had PJI due to RGM during 1969-2006 were reviewed to summarize its clinical characteristics, treatment, and outcome., Results: Eight patients developed 9 episodes of PJI (7 episodes involving the knee and 1 each involving the hip or elbow) due to RGM at a median of 312 weeks (range, 1-170 weeks) after prosthesis implantation. Patients presented with joint pain (7 patients), joint swelling (7 patients), and fever (3 patients), accompanied by an elevated erythrocyte sedimentation rate (median, 70.5 mm/h) and C-reactive protein level (median, 6 mg/dL). Mycobacterium chelonae (n=3), Mycobacterium abscessus (n=2), Mycobacterium fortuitum (n=3), and Mycobacterium smegmatis (n=1) were isolated from the 9 infected joints. Seven of 9 prostheses were resected, whereas 2 were retained after surgical debridement. Six of 8 patients received > or = 1 active antimicrobial agent for at least 6 months. During a median follow-up period of 33 weeks (range, 2.6-326 weeks) after surgical intervention, no clinical or microbiological relapses were observed. Reimplantation was performed successfully for 2 of 6 patients who underwent resection arthroplasty. The 2 patients with retained prosthesis continued to receive prolonged courses of suppressive antimicrobial therapy., Conclusions: RGM is a rare cause of PJI that should be suspected in patients with negative results of routine bacterial cultures. The combination of resection arthroplasty and antimicrobial therapy is the preferred approach. However, in cases involving retained prosthetic components, RGM infection may be suppressed with lifelong courses of effective antibiotic therapy.

Background: Spinal implant infections provide unique diagnostic and therapeutic challenges., Methods: We conducted a retrospective cohort study to evaluate risk factors for treatment failure in patients with early- and late-onset spinal implant infections at the Mayo Clinic (Rochester, MN) during 1994-2002., Results: We identified 30 patients with early-onset spinal implant infection and 51 patients with late-onset spinal implant infection. Twenty-eight of 30 patients with early-onset infection were treated with debridement, implant retention, and antimicrobial therapy. The estimated 2-year cumulative probability of survival free of treatment failure for patients with early-onset infection was 71% (95% confidence interval [CI], 51%-85%). Thirty-two of 51 patients with late-onset infection were treated with implant removal. Their estimated 2-year cumulative probability of survival free of treatment failure was 84% (95% CI, 66%-93%). For patients with early-onset infections, receiving oral antimicrobial suppression therapy was associated with increased cumulative probability of survival (hazard ratio, 0.2; 95% CI, 0.1-0.7). For patients with late-onset infections, implant removal was associated with increased cumulative probability of survival (hazard ratio, 0.3; 95% CI, 0.1-0.7)., Conclusions: Early-onset spinal implant infections are successfully treated with debridement, implant retention, and parenteral followed by oral suppressive antimicrobial therapy. Implant removal is associated with successful outcomes in late-onset infections.

Background: The ability of follow-up imaging examinations to predict treatment failure in patients with spine infections has not been well studied., Methods: We conducted a retrospective cohort analysis of patients with spine infection who had both baseline and 4-8-week follow-up imaging results available at the Mayo Clinic (Rochester, MN) during the period of 1994-2002. Follow-up imaging findings were categorized as improved, equivocal, or worse, compared with the baseline findings, on the basis of a simple grading system that focused on associated soft-tissue findings., Results: Baseline and 4-8-week follow-up imaging findings were available for 79 patients with spine infection who presented to the Mayo Clinic during 1994-2002. Thirty-five infections (44%) were due to Staphylococcus aureus, 9 (11%) were due to coagulase-negative staphylococci, and 16 (20%) were culture negative. Twenty-seven (34%), 38 (48%), and 14 (18%) follow-up images were graded improved, equivocal, or worse, respectively. The cumulative rates of 1-year survival free of microbiologically confirmed treatment failure were 100%, 89% (95% CI, 74%-96%), and 56% (95% CI, 24%-83%) for patients with improved, equivocal, and worse follow-up imaging findings, respectively (P=.004). Only 3 (6%) of 52 patients deemed to have had clinical improvement at the time of the follow-up imaging study experienced treatment failure. Elevated levels of inflammatory biomarkers identified 2 of these patients as high risk for treatment failure, and the levels were not performed for the third patient., Conclusions: Applying a simple grading scale to assess follow-up imaging examinations for patients with spinal infection stratifies their risk of treatment failure. Patients' clinical statuses and inflammatory biomarker responses may be helpful for selecting patients at high risk for treatment failure who should undergo follow-up magnetic resonance imaging.

Background: Debridement and retention of the prosthesis represents an attractive surgical modality for treatment of prosthetic joint infection, but risk factors for treatment failure require clarification., Methods: We conducted a retrospective cohort analysis of all patients with a prosthetic joint infection who were treated with debridement and retention of the prosthesis at the Mayo Clinic (Rochester, Minnesota) between 1995 and 1999., Results: Debridement and retention of the prosthesis was the initial treatment modality for 99 episodes of prosthetic joint infection that occurred in 91 patients who presented to the Mayo Clinic during 1995-1999. A total of 32% and 23% of all episodes were due to Staphylococcus aureus and coagulase-negative staphylococci, respectively. The median duration of intravenous antimicrobial therapy was 28 days (range, 1-90 days). Oral antimicrobial suppression was used in 89% of the episodes, for a median duration of 541 days (range, 5-2673 days). Treatment failure occurred in 53 episodes during a median follow-up period of 700 days (range, 1-2779 days). The 2-year survival rate free of treatment failure was 60% (95% confidence interval [CI], 50%-71%). Variables associated with an increased risk of treatment failure in multivariable analysis included the presence of a sinus tract (hazard ratio, 2.84; 95% CI, 1.48-5.44; P = .002) and a duration of symptoms prior to debridement of > or = 8 days (hazard ratio, 1.77; 95% CI, 1.02-3.07; P = .04)., Conclusions: Debridement and retention of the prosthesis is a common surgical modality at our institution to treat prosthetic joint infection. Risk factors independently associated with treatment failure include the presence of a sinus tract and duration of symptoms prior to debridement of > or = 8 days.

Background: Prosthetic joint infection in patients with rheumatoid arthritis is a serious complication of total joint arthroplasty. Little information is available on the outcome of medical and surgical treatments of prosthetic joint infection in patients with rheumatoid arthritis., Methods: We conducted a retrospective analysis of all patients with rheumatoid arthritis and a total hip or total knee arthroplasty infection evaluated at Mayo Clinic (Rochester, MN) between 1 January 1969 and 31 December 1995., Results: A total of 200 first episodes of prosthetic joint infection in 160 patients with rheumatoid arthritis were diagnosed during the study period. Thirty-seven percent of prosthetic joint infection episodes were due to Staphylococcus aureus. Of these episodes, 23% and 19% were treated with debridement and retention of components and 2-stage exchange, respectively. The type of surgical procedure was the only analyzed clinical variable that was associated with treatment failure (P < .001). Rates of 5-year survival free of treatment failure for patients with prosthetic joint infection episodes treated with debridement and retention of components, 2-stage exchange, and resection arthroplasty were 32% (95% confidence interval [CI], 21%-49%), 79% (95% CI, 66%-93%), and 61% (95% CI, 49%-74%), respectively., Conclusions: S. aureus is the most common pathogen among patients with rheumatoid arthritis with prosthetic joint infection. Two-stage exchange was used in only 19% of the prosthetic joint infection episodes among patients with rheumatoid arthritis during the study period, but it was associated with the best outcome. The variable most strongly associated with the outcome was the type of surgical procedure.

Debridement with retention of the prosthesis was the initial treatment modality for 19 cases of penicillin-susceptible streptococcal prosthetic joint infection that occurred in 18 patients who presented to the Mayo Clinic (Rochester, Minnesota) during 1969-1998. All of the cases of prosthetic joint infection occurred >30 days after implantation of the prosthesis, which was well fixed at the time of debridement. The median duration of symptoms before debridement was 4 days (range, 1-10 days). Treatment failure (defined as relapse of infection with the original microorganism) occurred in 2 cases (10.5%) during a median follow-up period of 3.9 years (range, 0.3-21.7 years). The 1-year cumulative risk of relapse was 11% (95% confidence interval, 0%-26%). Relapse of prosthetic joint infection due to penicillin-susceptible streptococci after debridement and retention of the prosthesis is uncommon. For patients who present with a well-fixed prosthesis and a short duration of symptoms, debridement with retention appears to be an effective treatment modality.

Fungal prosthetic joint infection (PJI) is rare, with Candida species being the most frequently reported pathogen in the medical literature. The risk of relapse following delayed reimplantation arthroplasty for candidal PJI is unknown. We describe 4 new cases and summarize 6 previously reported cases of candidal PJI treated with delayed reimplantation arthroplasty. Ninety percent of the patients received antifungal therapy. Eight patients received amphotericin B either alone or in combination with other antifungals. One patient received fluconazole alone. The median duration of time from resection arthroplasty to reimplantation for total hip and total knee arthroplasties was 8.6 and 2.3 months, respectively. Eight patients did not have relapse of candidal PJI following delayed reimplantation arthroplasty after a median duration of follow-up of 50.7 months (range, 2--73 months). Candidal PJI can be successfully treated with delayed reimplantation arthroplasty after receipt appropriate antifungal therapy.

We conducted a matched case-control study to determine risk factors for the development of prosthetic joint infection. Cases were patients with prosthetic hip or knee joint infection. Controls were patients who underwent total hip or knee arthroplasty and did not develop prosthetic joint infection. A multiple logistic regression model indicated that risk factors for prosthetic joint infection were the development of a surgical site infection not involving the prosthesis (odds ratio [OR], 35.9; 95% confidence interval [CI], 8.3-154.6), a National Nosocomial Infections Surveillance (NNIS) System surgical patient risk index score of 1 (OR, 1.7; 95% CI, 1.2-2.3) or 2 (OR, 3.9; 95% CI, 2.0-7.5), the presence of a malignancy (OR, 3.1; 95% CI, 1.3-7.2), and a history of joint arthroplasty (OR, 2.0; 95% CI, 1.4-3.0). Our findings suggest that a surgical site infection not involving the joint prosthesis, an NNIS System surgical patient risk index score of 1 or 2, the presence of a malignancy, and a history of a joint arthroplasty are associated with an increased risk of prosthetic joint infection.

Debridement and retention of the prosthesis was the initial treatment modality in 30 patients with 33 Staphylococcus aureus prosthetic joint infections (PJIs) who presented to the Mayo Clinic between 1980 and 1991. Treatment failure, defined as relapse of S. aureus PJI or occurrence of culture-negative PJI during continuous antistaphylococcal therapy, occurred in 21 of 33 prosthetic joints. The 1-year and 2-year cumulative probabilities of treatment failure were 54% (95% confidence interval [CI], 36%-71%) and 69% (95% CI, 52%-86%), respectively. A median of 4 additional surgical procedures (range, 1-9) were required to control the infection in the 21 prosthetic joints for which treatment failed. Prostheses that were debrided >2 days after onset of symptoms were associated with a higher probability of treatment failure than were those debrided within 2 days of onset (relative risk, 4.2; 95% CI, 1.6-10.3). These data suggest that debridement and retention of the prosthesis as the initial therapy for PJI due to S. aureus is associated with a high cumulative probability of treatment failure and that the probability of treatment failure may be related to the duration of symptoms.

Lactobacillemia is rare and, to our knowledge, previously undescribed in liver transplant patients. We reviewed the clinical records of all patients who had undergone orthotopic liver transplantation between January 1985 and August 1992 for whom a blood culture after transplantation yielded Lactobacillus species. A case-control study for determination of risk factors for lactobacillemia in this patient population was also performed. Eight cases of lactobacillus bacteremia were identified. All patients received nonabsorbable oral antibiotics for selective bowel decontamination. In addition, six of eight case patients received intravenous vancomycin prior to the development of lactobacillemia. The biliary anastomosis in each case patient was a Roux-en-Y choledochojejunostomy. Analysis of the case-control study revealed that the presence of a Roux-en-Y choledochojejunostomy at the time of lactobacillemia is a statistically significant risk factor (odds ratio [OR] = infinity, 95% confidence interval [CI] = 1.8-infinity, P < or = .05) but that prior administration of intravenous vancomycin is not a statistically significant risk factor (OR = 2.6, 95% CI = 0.38-30.0, P value not significant) for lactobacillemia. The use of selective bowel decontamination and of intravenous vancomycin in liver transplant patients may select for Lactobacillus species. Furthermore, a Roux-en-Y choledochojejunostomy may allow colonization of the intrahepatic biliary tract with enteric flora.