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      The World Association against Infection in Orthopaedics and Trauma (WAIOT) procedures for Microbiological Sampling and Processing for Periprosthetic Joint Infections (PJIs) and other Implant-Related Infections †

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          Abstract

          While implant-related infections continue to play a relevant role in failure of implantable biomaterials in orthopaedic and trauma there is a lack of standardised microbiological procedures to identify the pathogen(s). The microbiological diagnosis of implant-related infections is challenging due to the following factors: the presence of bacterial biofilm(s), often associated with slow-growing microorganisms, low bacterial loads, previous antibiotic treatments and, possible intra-operative contamination. Therefore, diagnosis requires a specific set of procedures. Based on the Guidelines of the Italian Association of the Clinical Microbiologists (AMCLI), the World Association against Infection in Orthopaedics and Trauma has drafted the present document. This document includes guidance on the basic principles for sampling and processing for implant-related infections based on the most relevant literature. These procedures outline the main microbiological approaches, including sampling and processing methodologies for diagnostic assessment and confirmation of implant-related infections. Biofilm dislodgement techniques, incubation time and the role of molecular approaches are addressed in specific sections. The aim of this paper is to ensure a standardised approach to the main microbiological methods for implant-related infections, as well as to promote multidisciplinary collaboration between clinicians and microbiologists.

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          Most cited references81

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          Coagulase-negative staphylococci.

          The definition of the heterogeneous group of coagulase-negative staphylococci (CoNS) is still based on diagnostic procedures that fulfill the clinical need to differentiate between Staphylococcus aureus and those staphylococci classified historically as being less or nonpathogenic. Due to patient- and procedure-related changes, CoNS now represent one of the major nosocomial pathogens, with S. epidermidis and S. haemolyticus being the most significant species. They account substantially for foreign body-related infections and infections in preterm newborns. While S. saprophyticus has been associated with acute urethritis, S. lugdunensis has a unique status, in some aspects resembling S. aureus in causing infectious endocarditis. In addition to CoNS found as food-associated saprophytes, many other CoNS species colonize the skin and mucous membranes of humans and animals and are less frequently involved in clinically manifested infections. This blurred gradation in terms of pathogenicity is reflected by species- and strain-specific virulence factors and the development of different host-defending strategies. Clearly, CoNS possess fewer virulence properties than S. aureus, with a respectively different disease spectrum. In this regard, host susceptibility is much more important. Therapeutically, CoNS are challenging due to the large proportion of methicillin-resistant strains and increasing numbers of isolates with less susceptibility to glycopeptides.
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            Sonication of removed hip and knee prostheses for diagnosis of infection.

            Culturing of samples of periprosthetic tissue is the standard method used for the microbiologic diagnosis of prosthetic-joint infection, but this method is neither sensitive nor specific. In prosthetic-joint infection, microorganisms are typically present in a biofilm on the surface of the prosthesis. We hypothesized that culturing of samples obtained from the prosthesis would improve the microbiologic diagnosis of prosthetic-joint infection. We performed a prospective trial comparing culture of samples obtained by sonication of explanted hip and knee prostheses to dislodge adherent bacteria from the prosthesis with conventional culture of periprosthetic tissue for the microbiologic diagnosis of prosthetic-joint infection among patients undergoing hip or knee revision or resection arthroplasty. We studied 331 patients with total knee prostheses (207 patients) or hip prostheses (124 patients); 252 patients had aseptic failure, and 79 had prosthetic-joint infection. With the use of standardized nonmicrobiologic criteria to define prosthetic-joint infection, the sensitivities of periprosthetic-tissue and sonicate-fluid cultures were 60.8% and 78.5% (P<0.001), respectively, and the specificities were 99.2% and 98.8%, respectively. Fourteen cases of prosthetic-joint infection were detected by sonicate-fluid culture but not by prosthetic-tissue culture. In patients receiving antimicrobial therapy within 14 days before surgery, the sensitivities of periprosthetic tissue and sonicate-fluid culture were 45.0% and 75.0% (P<0.001), respectively. In this study, culture of samples obtained by sonication of prostheses was more sensitive than conventional periprosthetic-tissue culture for the microbiologic diagnosis of prosthetic hip and knee infection, especially in patients who had received antimicrobial therapy within 14 days before surgery. Copyright 2007 Massachusetts Medical Society.
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              Definition of periprosthetic joint infection.

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                Author and article information

                Journal
                J Clin Med
                J Clin Med
                jcm
                Journal of Clinical Medicine
                MDPI
                2077-0383
                28 June 2019
                July 2019
                : 8
                : 7
                : 933
                Affiliations
                [1 ]Clinical Microbiology, Department of Biomedical Sciences for Health, University of Milan, 20100 Milano, Italy
                [2 ]Laboratory of Clinical Microbiology, AO Legnano Hospital, AMCLI, 20025 Milano, Italy
                [3 ]Residency Program in Orthopaedics and Traumatology, University of Milan, 20100 Milano, Italy
                [4 ]Department of Paediatric Orthopaedics and Spine Surgery, Children’s Orthopedic Centre, Mumbai 230532, India
                [5 ]Zerktouni Orthopaedic Clinic, Casablanca 20000, Morocco
                [6 ]Department of Prevention and Treatment of Wound Infection, R.R. Vreden Russian Research Institute of Traumatology and Orthopaedics, 33701 S. Petersburg, Russia
                [7 ]Traumatology & Orthopedics Department, Baku Health Clinic, 1005 Baku, Azerbaigian
                [8 ]Department of Orthopaedics, British Hospital Buenos Aires, B1675 Buenos Aires, Argentina
                [9 ]Hull University Teaching Hospitals, Anlaby Road, Hull HU3 2JZ, UK
                [10 ]Department of Infectious Diseases, Monash University, Melbourne VIC 3004, Australia
                [11 ]Department of Odontoiatric and Surgical Sciences, University of Milan, 20100 Milano, Italy
                [12 ]Studio Medico Cecca-Romanò, corso Venezia, 2, 20121 Milano, Italy
                [13 ]Romano Institute, Rruga Ibrahim Rugova, Tirane 1001, Albania
                Author notes
                [* ]Correspondence: lorenzo.drago@ 123456unimi.it
                [†]

                Originally proposed and endorsed by the Italian Association of Clinical Microbiologists (AMCLI).

                Author information
                https://orcid.org/0000-0002-5206-540X
                https://orcid.org/0000-0001-5719-0739
                https://orcid.org/0000-0003-2370-2438
                Article
                jcm-08-00933
                10.3390/jcm8070933
                6678965
                31261744
                4fcb265e-3269-4c24-af02-bdb5a2f78d7b
                © 2019 by the authors.

                Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/).

                History
                : 03 June 2019
                : 26 June 2019
                Categories
                Review

                microbiology pji,infection,pji,peri-prosthetic joint,implant-related,biofilm,diagnosis,definition,pathogen,waiot

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