Can we rely on histopathological results for the diagnosis of prosthetic joint infection?

BACKGROUND: Histopathology is one of the diagnostic criteria for prosthetic joint infection (PJI) proposed by all academic societies. The aim of this study was to compare histopathological and microbiological results from samples taken intraoperatively at the same site in patients with suspected or proven PJI. PATIENTS AND METHODS: We conducted a monocenter retrospective study including all patients having undergone surgery from 2007 to 2015 with suspected or proven PJI. During surgery, both histopathological and microbiological samples were taken. Patients with a history of antimicrobial treatment 2 weeks prior to surgery were excluded. We considered as major criteria and gold standard for PJI diagnosis the presence of a sinus tract communication and/or the same microorganism in at least two cultures. RESULTS: Finally, 181 patients who underwent 309 surgeries were included. The median number of samples per surgery was 4 (interquartile range (IQR) = 3-5) for histopathology and 5 (IQR = 4-6) for microbiology. Major criteria were observed in 177 patients (57.3%), while positive histology in at least one intraoperative sample was present in 119 (38.5%). The concordance was 74%. The sensitivity and specificity of histopathology were 61% and 92% respectively. Available "histopathology-culture" sample pairs numbered 1247. Among them, positive histopathology was found in 292 samples (23%) and culture in 563 (45%). Concordance was 64%. The highest correlation was observed for very early infection (<1 month) (OR: 9.1, 95% CI: 3.6-23) and for virulent microorganisms, such as Staphylococcus aureus (OR: 7.8, 95% CI: 5.2-11.8), Streptococci (OR:7.8; 95% CI: 4-15.2) or Enterobacterales (OR: 7.4; 95% CI: 4.2-13.1). CONCLUSION: Histopathologic examination is a valuable criterion for PJI diagnosis, but it may lack sensitivity for chronic infections or due to low-virulence pathogens.

Characteristics of Enterobacter cloacae prosthetic joint infections.

OBJECTIVES: Enterobacter cloacae prosthetic joint infections (PJI) are rare and poorly documented. PATIENTS AND METHODS: We conducted a retrospective and monocentric study in an orthopedic unit supporting complex bone and joint infections. Between 2012 and 2016 we collected background, clinical, biological, and microbiological data from 20 patients presenting with prosthetic joint infection and positive for E. cloacae, as well as data on their surgical and medical treatment and outcome. RESULTS: Infections were localized in the hip (n=14), knee (n=5), or ankle (n=1). The median time between arthroplasty and septic revision was three years. Fourteen patients (70%) had undergone at least two surgeries due to previous prosthetic joint infections. The median time between the last surgery and the revision for E. cloacae infection was 31 days. Eleven patients (55%) were infected with ESBL-producing strains. The most frequently used antibiotics were carbapenems (n=9), cefepime (n=7), quinolones (n=7), and fosfomycin (n=4). The infection was cured in 15 patients (78.9%) after a 24-month follow-up. Five patients had a recurrent infection with another microorganism and four patients had a relapse of E. cloacae infection. The global success rate was 52.7% (58.3% for DAIR and 75% for DAIR+ciprofloxacin). CONCLUSION: Prosthetic joint infections due to E. cloacae usually occur early after the last prosthetic surgery, typically in patients with complex surgical and medical histories. The success rate seems to be increased when DAIR is associated with ciprofloxacin.

[Pica: a descriptive study of patients in a speciality medical center]. / Le pica: étude descriptive dans une population de patients hospitalisés en psychiatrie.

According to the DSM IV, pica is a trouble of alimentary behavior, which is characterized by the ingestion of non-nutriment substances during at least on the month. The main objective of this study conducted at the Clermont-de-l'Oise Interdepartmental Medical Center is to evaluate pica's prevalence for hospitalized patients. Secondary objectives are to describe clinical characteristics, complications and outcome upon the different therapeutic approaches. The patients hospitalized in the Adult and/or Pediatric Department of Psychiatry, which fulfilled the 4 criteria of the DSM IV, were considered eligible for the study. In order to better evaluate the severity of behavioral troubles evoked by item D of DSM IV definition, we elaborated specific severity and preoccupation scales. The severity scale reflects the complications due to the ingestion of the non-nutriment substances, the encountered risks in the case of persistence of these troubles as well as the patient's management. The preoccupation scale reflects the medical team's involvement towards the patient in order to prevent life-threatening complications. The two scales are graded from 0 to 5 according to the severity or to the degree of preoccupation, respectively. Only patients with scores 3 were considered as fulfilling the severity criteria. Among the 943 hospitalized patients at a selected time period, 23 adult patients have been considered eligible. According to these data, prevalence of pica was estimated at 2.44%. This value may seem an underestimation when compared to the values reported in the medical literature, which range from 9 to 25%. Additionally, among the 108 hospitalized infant patients, none fulfilled DSM IV criteria, which is surprising, as pica is relatively common in childhood. These results may be explained by the use of the more restrictive criteria of the DSM IV and also by the difficulties encountered in considering pica as an independent medical condition. Indeed, pica is often a secondary diagnosis associated with other psychiatric conditions characterized by profound mental deterioration. Two pathogenic factors were constantly searched in the medical records: iron-deficiency anemia and psychopathology. Cultural factors can be a priori eliminated, as most of these patients are in rupture with their family environment since low ages. Only two patients presented with iron-deficiency anemia and its correction did not result in pica's improvement. These findings do not support the -studies presenting pica as an iron-deficiency anemia induced trouble, which regress after a well-conducted iron replacement. Most patients were found to have precocious lack of affect in their medical history. All patients presented other associated psychiatric troubles including severe mental impairment (48%) and dysharmonic development (26%), as well as autistic troubles and schizophrenia. These data concur with other studies, which associate pica to other psychiatric disorders. Gluttony is a widely represented symptom in our study population (87%) and predisposes to food aspiration. It is the mark of frenetic orality and concerns comestible as well as non-comestible compounds. The ingestion of non-nutriment compounds could therefore be considered as an incapacity of discerning among different mouth-introduced substances. Auto- and hetero-aggressive disorders have been reported in 77% of the patients. These behaviors arise mostly in the phase of seeking of substances, especially if these are particularly attractive. The enhancement of the -anxiety, which often arises in the eventuality of hindering of the act, as well as the soothing effect of the ingestion, suggests a compulsive activity. This compulsive activity could be related to an addictive conduct. Pica could therefore be related to obsessive-compulsive disorders and benefit from its specific therapy, either behavioral or chemotherapy with serotonin-recapture inhibitors. The most common clinical forms of pica were phytophagia and geophagia, probably due to the facility of access to these substances. However, 31 distinct substances have been identified in our study. Pica's evolution often implies severe complications, which are sometimes life threatening in spite of a well-conducted treatment. Severity factors include the iteration of medical and surgical complications, as well as the type of ingested products. Our results show a high incidence of surgical complications, essentially gastro-intestinal. Due to the elevated incidence of complications and to the high rate of mortality, some authors proposed systematical search of pica for any gastro-intestinal troubles arising in patients suffering from mental disorders. For these patients for whom anamnesis is often difficult, a standard X-ray of the abdomen is an essential imaging study. Respiratory complications come in second position and infectious complications are seen mostly for the geo- and coprophagia-suffering patients, which contract intestinal parasitosis. Because of its multifactor causality, treatment of pica is complex, and results are often deceiving. Symptomatic neuroleptic therapy results in transient improvement and is indicated especially in delirious patients. Psychotherapy with behavioral approaches and different institutional approaches can be proposed. Indeed, pica could be considered as an acquired behavior, which could benefit from cognitive and behavioral therapies. Institutional management including supportive and compassionate care, restoration of self-confidence is interesting for these patients. Some authors even suggest that pica might be considered as a good indicator of the institution's care quality.

[Analysis of hematopoietic growth factor prescriptions in 19 french cancer centers]. / Analyse de la prescription de facteurs de croissance hématopoïétique dans 19 centres anticancéreux français. Groupe de pharmaciens de la Fédération nationale des centres de lutte contre le cancer.

Medical prescription of hematopoietic growth factors (HGF) was analysed in 19 anticancer french centers during 2 months. About 4% of anticancer chemotherapeutic cycles prescribed during this period were supported by HGF prescription. The mean duration of treatment was 8 days. Among the 755 collected prescriptions, two tumor localizations represented about 50% of the prescriptions: malignant non Hodgkin lymphomas and breast cancer. The other main localizations concerned adult or pediatric soft tissue sarcomas (18%), testicular cancer (7%) and gynecologic tumors (6%). The prescription for primary prophylaxis for febrile neutropenia remains the main use of HGF (44%). The respect of the guidelines established by the F|d|ration nationale des centres de lutte contre le cancer was analyzed. Overall, 66% of the prescriptions were in adequation with these guidelines. Whereas the consommation of HGF decreased in the 19 considered institutions, it did not reach a plateau and could decrease in institutions which are awaked to the international and national recommendations.