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1.  2011 Musculoskeletal Infection Society: Editorial Comment 
doi:10.1007/s11999-012-2527-9
PMCID: PMC3441992  PMID: 22903281
2.  INCIDENCE, SECULAR TRENDS AND OUTCOMES OF PROSTHETIC JOINT INFECTION (PJI): A POPULATION BASED STUDY, OLMSTED COUNTY, MINNESOTA, 1969 – 2007 
Context
The epidemiology of prosthetic joint infection (PJI) in a population based cohort has not been studied in the United States.
Objectives
To provide an accurate assessment of the true incidence, secular trends, clinical manifestations, microbiology and treatment outcomes of PJI in a population based cohort.
Design
Historical cohort study
Setting
Olmsted County, Minnesota, United States of America.
Participants
Residents who underwent total knee arthroplasty (TKA) or total hip arthroplasty (THA) between 1/ 1/ 1969 and 12/ 31/ 2007.
Methods
Incidence rates and trends in PJI were assessed using the Kaplan Meier method and log-rank test, as were treatment outcomes among PJI cases.
Results
7375 THA or TKA were implanted in residents of Olmsted County during the study period. Seventy five discrete joints in 70 individuals developed PJI, during a mean(+/− SD) follow up of 6.8 (+/− 6.1) years. The cumulative incidence of PJI was 0.5%, 0.8% and 1.4% after 1, 5 and 10 years following arthroplasty, respectively. Overall, the rate of survival free of clinical failure after treatment of PJI was 76.8 % ( 95% CI: 64.3 – 85.2) and 65.2 % ( 95% CI: 33.1 – 76.2) at 3 years and 5 years, respectively. The incidence and treatment outcomes did not significantly differ by decade of implantation, patient age at implantation, gender or joint location.
Conclusions
The incidence of PJI is relatively low in a population based cohort, and is a function of age of the prosthesis. Incidence trends and outcomes have not significantly changed over the past forty years.
doi:10.1086/668421
PMCID: PMC3602045  PMID: 23143357
3.  A Case of Q Fever Prosthetic Joint Infection and Description of an Assay for Detection of Coxiella burnetii 
We present the first published case of Coxiella burnetii prosthetic joint infection. Diagnosis was established with PCR and culture of periprosthetic tissue and synovial fluid (and serology). A novel PCR assay is described herein. Q fever should be considered in patients with prosthetic joint infection without an identified pathogen.
doi:10.1128/JCM.02352-12
PMCID: PMC3536193  PMID: 23077126
4.  Prosthetic Joint Infection Diagnosis Using Broad-Range PCR of Biofilms Dislodged from Knee and Hip Arthroplasty Surfaces Using Sonication 
Journal of Clinical Microbiology  2012;50(11):3501-3508.
Periprosthetic tissue and/or synovial fluid PCR has been previously studied for prosthetic joint infection (PJI) diagnosis; however, few studies have assessed the utility of PCR on biofilms dislodged from the surface of explanted arthroplasties using vortexing and sonication (i.e., sonicate fluid PCR). We compared sonicate fluid 16S rRNA gene real-time PCR and sequencing to culture of synovial fluid, tissue, and sonicate fluid for the microbiologic diagnosis of PJI. PCR sequences generating mixed chromatograms were decatenated using RipSeq Mixed. We studied sonicate fluids from 135 and 231 subjects with PJI and aseptic failure, respectively. Synovial fluid, tissue, and sonicate fluid culture and sonicate fluid PCR had similar sensitivities (64.7, 70.4, 72.6, and 70.4%, respectively; P > 0.05) and specificities (96.9, 98.7, 98.3, and 97.8%, respectively; P > 0.05). Combining sonicate fluid culture and PCR, the sensitivity was higher (78.5%, P < 0.05) than those of individual tests, with similar specificity (97.0%). Thirteen subjects had positive sonicate fluid culture but negative PCR, and 11 had negative sonicate fluid culture but positive PCR (among which 7 had prior use of antimicrobials). Broad-range PCR and culture of sonicate fluid have equivalent performance for PJI diagnosis.
doi:10.1128/JCM.00834-12
PMCID: PMC3486250  PMID: 22895042
5.  Temporal Trends in the Incidence of Surgical Site Infections in Patients Undergoing Coronary Artery Bypass Graft Surgery: A Population-Based Cohort Study, 1993 to 2008 
Mayo Clinic Proceedings  2012;87(11):1054-1061.
Objective
To determine the incidence of and temporal trends in surgical site infections (SSIs) in patients underoing coronary artery bypass graft (CABG) surgery.
Methods
A population-based cohort study was conducted to describe the epidemiologic features of SSI in Olmsted County, Minnesota, between January 1, 1993, and December 31, 2008, using the Rochester Epidemiology Project. Period-specific incidence rates (in-hospital or within 30 days outside the hospital) were calculated. Logistic regression analysis was used to adjust for potential confounders that could affect temporal trends in SSI incidence rates.
Results
During the 16-year study, of 1424 residents of Olmsted County who underwent CABG surgery, 1189 (83%) had isolated CABG and 235 (17%) had combined CABG and valve surgery. The overall SSI incidence rate was 7.0% (95% confidence interval [CI], 5.7%-8.4%). The incidence rate of superficial sternal SSI was 2.0% (95% CI, 1.2%-2.7%) and of deep sternal SSI was 1.5% (95% CI, 0.9%-2.2%). The leg harvest site infection rate was 3.6% (95% CI, 2.6 %-4.5%). The incidence rate decreased over time with a statistically significant linear trend. The adjusted odds ratio (95% CI) of SSI showed a decreasing linear trend: 0.39 (0.19-0.81) vs 0.50 (0.27-0.93) vs 0.83 (0.48-1.42) vs reference for 2005-2008 vs 2001-2004 vs 1997-2000 vs 1993-1996.
Conclusion
In this population-based surveillance study of patients undergoing CABG surgery, the incidence of SSI decreased markedly between 1993 and 2008 in patients in Olmsted County. The factors responsible for this decrease are the focus of ongoing investigations.
doi:10.1016/j.mayocp.2012.05.026
PMCID: PMC3532679  PMID: 23127732
CABG, coronary artery bypass graft; CDC, Centers for Disease Control and Prevention; LHSI, leg harvest site infection; REP, Rochester Epidemiology Project; SSI, surgical site Infection; STS, Society of Thoracic Surgeons
6.  Increased risk of prosthetic joint infection associated with esophago-gastro-duodenoscopy with biopsy 
Acta Orthopaedica  2013;84(1):82-86.
Background
There are no prospective data regarding the risk of prosthetic joint infection following routine gastrointestinal endoscopic procedures. We wanted to determine the risk of prosthetic hip or knee infection following gastrointestinal endoscopic procedures in patients with joint arthroplasty.
Methods
We conducted a prospective, single-center, case-control study at a single, tertiary-care referral center. Cases were defined as adult patients hospitalized for prosthetic joint infection of the hip or knee between December 1, 2001 and May 31, 2006. Controls were adult patients with hip or knee arthroplasties but without a diagnosis of joint infection, hospitalized during the same time period at the same orthopedic hospital. The main outcome measure was the odds ratio (OR) of prosthetic joint infection after gastrointestinal endoscopic procedures performed within 2 years before admission.
Results
339 cases and 339 controls were included in the study. Of these, 70 cases (21%) cases and 82 controls (24%) had undergone a gastrointestinal endoscopic procedure in the preceding 2 years. Among gastrointestinal procedures that were assessed, esophago-gastro-duodenoscopy (EGD) with biopsy was associated with an increased risk of prosthetic joint infection (OR = 3, 95% CI: 1.1–7). In a multivariable analysis adjusting for sex, age, joint age, immunosuppression, BMI, presence of wound drain, prior arthroplasty, malignancy, ASA score, and prothrombin time, the OR for infection after EGD with biopsy was 4 (95% CI: 1.5–10).
Interpretation
EGD with biopsy was associated with an increased risk of prosthetic joint infection in patients with hip or knee arthroplasties. This association will need to be confirmed in other epidemiological studies and adequately powered prospective clinical trials prior to recommending antibiotic prophylaxis in these patients.
doi:10.3109/17453674.2013.769079
PMCID: PMC3584609  PMID: 23350577
8.  Practical Considerations in the Use of Outpatient Antimicrobial Therapy for Musculoskeletal Infections 
Mayo Clinic Proceedings  2012;87(1):98-105.
Successful treatment of many musculoskeletal infections often requires an extended course of outpatient antimicrobial therapy, much of which is administered parenterally outside the hospital under the guidance of an infectious disease specialist. Delivery of outpatient parenteral antimicrobial therapy (OPAT) may occur in physicians' offices, ambulatory infusion centers, or hospital clinics but most frequently is done in patients' homes, often by the patients themselves. In this article, we outline the essential elements of outpatient antimicrobial therapy for musculoskeletal infections with particular emphasis on OPAT, including patient selection and evaluation; antimicrobial administration, including the route, duration, and complications of central venous access; and clinical and laboratory monitoring of antimicrobial therapy. We believe that primary care physicians, orthopedists, and infectious disease specialists caring for patients with musculoskeletal infections should become familiar with the use of, indications for, and complications of OPAT.
doi:10.1016/j.mayocp.2011.11.005
PMCID: PMC3498104  PMID: 22212975
9.  C-Reactive Protein, Erythrocyte Sedimentation Rate and Orthopedic Implant Infection 
PLoS ONE  2010;5(2):e9358.
Background
C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) have been shown to be useful for diagnosis of prosthetic hip and knee infection. Little information is available on CRP and ESR in patients undergoing revision or resection of shoulder arthroplasties or spine implants.
Methods/Results
We analyzed preoperative CRP and ESR in 636 subjects who underwent knee (n = 297), hip (n = 221) or shoulder (n = 64) arthroplasty, or spine implant (n = 54) removal. A standardized definition of orthopedic implant-associated infection was applied. Receiver operating curve analysis was used to determine ideal cutoff values for differentiating infected from non-infected cases. ESR was significantly different in subjects with aseptic failure infection of knee (median 11 and 53.5 mm/h, respectively, p = <0.0001) and hip (median 11 and 30 mm/h, respectively, p = <0.0001) arthroplasties and spine implants (median 10 and 48.5 mm/h, respectively, p = 0.0033), but not shoulder arthroplasties (median 10 and 9 mm/h, respectively, p = 0.9883). Optimized ESR cutoffs for knee, hip and shoulder arthroplasties and spine implants were 19, 13, 26, and 45 mm/h, respectively. Using these cutoffs, sensitivity and specificity to detect infection were 89 and 74% for knee, 82 and 60% for hip, and 32 and 93% for shoulder arthroplasties, and 57 and 90% for spine implants. CRP was significantly different in subjects with aseptic failure and infection of knee (median 4 and 51 mg/l, respectively, p<0.0001), hip (median 3 and 18 mg/l, respectively, p<0.0001), and shoulder (median 3 and 10 mg/l, respectively, p = 0.01) arthroplasties, and spine implants (median 3 and 20 mg/l, respectively, p = 0.0011). Optimized CRP cutoffs for knee, hip, and shoulder arthroplasties, and spine implants were 14.5, 10.3, 7, and 4.6 mg/l, respectively. Using these cutoffs, sensitivity and specificity to detect infection were 79 and 88% for knee, 74 and 79% for hip, and 63 and 73% for shoulder arthroplasties, and 79 and 68% for spine implants.
Conclusion
CRP and ESR have poor sensitivity for the diagnosis of shoulder implant infection. A CRP of 4.6 mg/l had a sensitivity of 79 and a specificity of 68% to detect infection of spine implants.
doi:10.1371/journal.pone.0009358
PMCID: PMC2825262  PMID: 20179760

Results 1-9 (9)