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Prosthetic Joint Infection of the Hip: Cause and Effect
Örebro universitet, Institutionen för medicinska vetenskaper.
2021 (Engelska)Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
Abstract [en]

Every year, 18 000 patients in Sweden and more than 1 million worldwide undergo total hip arthroplasty (THA). The operation is of great benefit to patients, but is associated with several complications. Prosthetic joint infections (PJIs) are among the most common complications, and can be devastating in terms of suffering for the patient and cost for the healthcare provider. The aim of this thesis was to investigate different aspects of PJIs in order to gain a better understanding of the causes and effects of infection. 

Four studies were conducted covering genomic analysis of the causative organism, identification of risk factors for failure of treatment, evaluation of a national infection control program aimed at reducing the burden of infections (PRISS: Prosthesis-related infections shall be stopped), and examination of the long-term impact of a PJI on the patient’s health through patient-reported measurement questionnaires.

The main findings were as follows. Commensal bacteria such as Cutibacterium avidum have the potential to cause PJIs, and should be specially accounted for when performing hip surgery with an anterior approach. S. aureus is both a commensal and a pathogen with invasive capacity, and the commensal strains do not differ from the PJI strains regarding prevalence of virulence genes and clonal complexes. The genomic traits of pathogens had no impact on treatment success or eradication of infection in S. aureus PJIs The long-term effects of a PJI in the hip include increased mortality, lower quality of life, and decreased hip function. The incidence of PJIs was higher following the PRISS project. Increasing risk factors contributing to PJI explain the increasing incidence of PJI after primary THA.

In conclusion, PJIs of the hip have multifactorial causes which are difficult to reduce, and long-term effects are severe.

Ort, förlag, år, upplaga, sidor
Örebro: Örebro University , 2021. , s. 98
Serie
Örebro Studies in Medicine, ISSN 1652-4063 ; 246
Nyckelord [en]
Prosthetic joint infection, infection, arthroplasty, hip, Staphylococcus aureus, Cutibacterium avidum, hip, outcome, PROM
Nationell ämneskategori
Kirurgi
Identifikatorer
URN: urn:nbn:se:oru:diva-92269ISBN: 978-91-7529-398-1 (tryckt)OAI: oai:DiVA.org:oru-92269DiVA, id: diva2:1562853
Disputation
2021-10-01, Örebro universitet, Campus USÖ, hörsal C1, Södra Grev Rosengatan 32, Örebro, 09:00 (Svenska)
Opponent
Handledare
Tillgänglig från: 2021-06-09 Skapad: 2021-06-09 Senast uppdaterad: 2023-08-29Bibliografiskt granskad
Delarbeten
1. Propionibacterium avidum as an Etiological Agent of Prosthetic Hip Joint Infection
Öppna denna publikation i ny flik eller fönster >>Propionibacterium avidum as an Etiological Agent of Prosthetic Hip Joint Infection
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2016 (Engelska)Ingår i: PLOS ONE, E-ISSN 1932-6203, Vol. 11, nr 6, artikel-id e0158164Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Propionibacterium acnes is well-established as a possible etiologic agent of prosthetic joint infections (PJIs). Other Propionibacterium spp. have occasionally been described as a cause of PJIs, but this has not previously been the case for P. avidum despite its capacity to form biofilm. We describe two patients with prosthetic hip joint infections caused by P. avidum. Both patients were primarily operated with an anteriorly curved skin incision close to the skin crease of the groin, and both were obese. Initial treatment was performed according to the DAIR procedure (debridement, antibiotics, and implant retention). In case 1, the outcome was successful, but in case 2, a loosening of the cup was present 18 months post debridement. The P. avidum isolate from case 1 and two isolates from case 2 (obtained 18 months apart) were selected for whole genome sequencing. The genome of P. avidum obtained from case 1 was approximately 60 kb larger than the genomes of the two isolates of case 2. These latter isolates were clonal with the exception of SNPs in the genome. All three strains possessed the gene cluster encoding exopolysaccharide synthesis.

P. avidum has a pathogenic potential and the ability to cause clinically relevant infections, including abscess formation, in the presence of foreign bodies such as prosthetic joint components. Skin incision in close proximity to the groin or deep skin crease, such as the anteriorly curved skin incision approach, might pose a risk of PJIs by P. avidum, especially in obese patients.

Ort, förlag, år, upplaga, sidor
San Francisco: Public Library of Science, 2016
Nationell ämneskategori
Infektionsmedicin
Identifikatorer
urn:nbn:se:oru:diva-51157 (URN)10.1371/journal.pone.0158164 (DOI)000378859400034 ()27355425 (PubMedID)2-s2.0-84977672350 (Scopus ID)
Anmärkning

Funding Agencies:

Foundation for Medical Research at Orebro University Hospital (Nyckelfonden)

Region Örebro County 199021

Research committee of Örebro University

Tillgänglig från: 2016-07-01 Skapad: 2016-07-01 Senast uppdaterad: 2021-09-07Bibliografiskt granskad
2. Genomic characterization and outcome of prosthetic joint infections caused by Staphylococcus aureus
Öppna denna publikation i ny flik eller fönster >>Genomic characterization and outcome of prosthetic joint infections caused by Staphylococcus aureus
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2020 (Engelska)Ingår i: Scientific Reports, E-ISSN 2045-2322, Vol. 10, nr 1, artikel-id 5938Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Staphylococcus aureus is a commensal colonizing the skin and mucous membranes. It can also act as a pathogen, and is the most common microorganism isolated from prosthetic joint infections (PJIs). The aim of this study was to explore the genomic relatedness between commensal and PJI S. aureus strains as well as microbial traits and host-related risk factors for treatment failure. Whole-genome sequencing (WGS) was performed on S. aureus isolates obtained from PJIs (n = 100) and control isolates from nares (n = 101). Corresponding clinical data for the PJI patients were extracted from medical records. No PJI-specific clusters were found in the WGS phylogeny, and the distribution of the various clonal complexes and prevalence of virulence genes among isolates from PJIs and nares was almost equal. Isolates from patients with treatment success and failure were genetically very similar, while the presence of an antibiotic-resistant phenotype and the use of non-biofilm-active antimicrobial treatment were both associated with failure.In conclusion, commensal and PJI isolates of S. aureus in arthroplasty patients were genetically indistinguishable, suggesting that commensal S. aureus clones are capable of causing PJIs. Furthermore, no association between genetic traits and outcome could be demonstrated, stressing the importance of patient-related factors in the treatment of S. aureus PJIs.

Ort, förlag, år, upplaga, sidor
Nature Publishing Group, 2020
Nationell ämneskategori
Infektionsmedicin Mikrobiologi inom det medicinska området
Identifikatorer
urn:nbn:se:oru:diva-81038 (URN)10.1038/s41598-020-62751-z (DOI)000563494300002 ()32246045 (PubMedID)2-s2.0-85083042211 (Scopus ID)
Anmärkning

Funding Agencies:

Research Committee of Orebro University, Region Örebro County, Örebro, Sweden  OLL735561

Centre for Clinical Research, Region Värmland, Karlstad, Sweden  LIVFOU-842521 LIVFOU-741321

Örebro University 

Tillgänglig från: 2020-04-06 Skapad: 2020-04-06 Senast uppdaterad: 2023-08-29Bibliografiskt granskad
3. What Are the Long-term Outcomes of Mortality, Quality of Life, and Hip Function after Prosthetic Joint Infection of the Hip? A 10-year Follow-up from Sweden
Öppna denna publikation i ny flik eller fönster >>What Are the Long-term Outcomes of Mortality, Quality of Life, and Hip Function after Prosthetic Joint Infection of the Hip? A 10-year Follow-up from Sweden
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2021 (Engelska)Ingår i: Clinical Orthopaedics and Related Research, ISSN 0009-921X, E-ISSN 1528-1132, Vol. 479, nr 10, s. 2203-2213Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

BACKGROUND: Prosthetic joint infection (PJI) is a complication after arthroplasty that negatively affects patient health. However, prior reports have not addressed the long-term consequences of hip PJI in terms of patient mortality, quality of life, and hip function.

QUESTIONS/PURPOSES: At a minimum of 10 years after PJI in patients undergoing primary THA, in the context of several large, national databases in Sweden, we asked: (1) Is mortality increased for patients with PJI after THA compared with patients with a noninfected THA? (2) Does PJI of the hip have a negative influence on quality of life as measured by the Euro-QoL-5D-5L (EQ-5D-5L), ambulatory aids, residential status, and hip function as measured by the Oxford Hip Score (OHS)? (3) Which factors are associated with poor patient-reported outcome measure (PROMs) for patients with PJI after primary THA?

METHODS: This study included 442 patients with a PJI after primary THA, from a previously published national study, including all patients with a THA performed from 2005 to 2008 in Sweden (n = 45,570) recruited from the Swedish Hip Arthroplasty Registry (SHAR). Possible deep PJIs were identified in the Swedish Dispensed Drug Registry and verified by review of medical records. Mortality in patients with PJI was compared with the remaining cohort of 45,128 patients undergoing primary THA who did not have PJI. Mortality data were retrieved from the SHAR, which in turn is updated daily from the population registry. A subgroup analysis of patients who underwent primary THA in 2008 was performed to adjust for the effect of comorbidities on mortality, as American Society of Anesthesiologists (ASA) scores became available in the SHAR at that time. For the PROM analysis, we identified three controls matched by age, gender, indication for surgery, and year of operation to each living PJI patient. A questionnaire including EQ-5D-5L, ambulatory aids, residential status, and OHS was collected from patients with PJI and controls at a mean of 11 years from the primary procedure. Apart from age and gender, we analyzed reoperation data (such as number of reoperations and surgical approach) and final prosthesis in situ to explore possible factors associated with poor PROM results.

RESULTS: After controlling for differences in sex, age, and indication for surgery, we found the all-cause 10-year mortality higher for patients with PJI (45%) compared with patients undergoing THA without PJI (29%) (odds ratio 1.4 [95% CI 1.2 to 1.6]; p < 0.001). The questionnaire, with a minimum of 10 years of follow-up, revealed a lower EQ-5D-5L index score (0.83 versus 0.94, -0.13 [95% CI -0.18 to -0.08; p < 0.001]), greater proportion of assisted living (21% versus 12%, OR 2.0 [95% CI 1.2 to 3.3]; p = 0.01), greater need of ambulatory aids (65% versus 42%, OR 3.1 [95% 2.1 to 4.8]; p < 0.001), and a lower OHS score (36 versus 44, -5.9 [-7.7 to -4.0]; p < 0.001) for patients with PJI than for matched controls. Factors associated with lower OHS score for patients with PJI were three or more reoperations (-8.0 [95% CI -13.0 to -3.2]; p = 0.01) and a direct lateral approach used at revision surgery compared with a posterior approach (-4.3 [95% CI -7.7 to -0.9]; p = 0.01).

CONCLUSION: In this study, we found that PJI after THA has a negative impact on mortality, long-term health-related quality of life, and hip function. Furthermore, the subgroup analysis showed that modifiable factors such as the number of reoperations and surgical approach are associated with poorer hip function. This emphasizes the importance of prompt, proper initial treatment to reduce repeated surgery to minimize the negative long-term effects of hip PJI.

LEVEL OF EVIDENCE: Level III, therapeutic study.

Ort, förlag, år, upplaga, sidor
Lippincott Williams & Wilkins, 2021
Nationell ämneskategori
Ortopedi
Identifikatorer
urn:nbn:se:oru:diva-92063 (URN)10.1097/CORR.0000000000001838 (DOI)000711675000016 ()34061486 (PubMedID)2-s2.0-85117426152 (Scopus ID)
Anmärkning

Funding agency:

Research Committee of Region Örebro län

Tillgänglig från: 2021-06-02 Skapad: 2021-06-02 Senast uppdaterad: 2023-06-30Bibliografiskt granskad
4. National infection control program has no effect on postoperative infections after total hip arthroplasty
Öppna denna publikation i ny flik eller fönster >>National infection control program has no effect on postoperative infections after total hip arthroplasty
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(Engelska)Manuskript (preprint) (Övrigt vetenskapligt)
Nationell ämneskategori
Kirurgi
Identifikatorer
urn:nbn:se:oru:diva-94137 (URN)
Tillgänglig från: 2021-09-07 Skapad: 2021-09-07 Senast uppdaterad: 2021-09-28Bibliografiskt granskad

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