Clinical features and outcome of bone and joint infections with streptococcal involvement: 5-year experience of interregional reference centres in the south of France.

Streptococcal bone and joint infections are less common than staphylococcal cases. Few studies have reported the cases with well-identified Streptococcus species. Their clinical features and prognosis are not clearly known to date. Moreover, no treatment regimen has yet been clarified. We reviewed the streptococcal bone and joint infection cases managed in our centres from January 2009 to December 2013. We described the epidemiology, clinical and microbiologic characteristics, treatment approach and outcome. Among the 93 cases, 83% of patients were men with a median age of 60 years, and 90% of patients had comorbidities or risk factors. Bacteraemia occurred in 14% of cases. Serious complications occurred in six patients, including severe sepsis (two cases) and infective endocarditis (two cases). Orthopaedic device infections were observed in 35% of cases, including 17 patients with internal osteosynthesis device infection, 14 with prosthetic joint infection and three with vertebral osteosynthesis device infection. The median time between orthopaedic device implantation and onset of infection was 447 days. Fourteen species of Streptococcus were identified, including 97 isolates using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry and three isolates using molecular identification. The five most represented species included S. agalactiae (37%), S. dysgalactiae (12%), S. anginosus (11%), S. constellatus (10%) and S. pneumoniae (9%). Streptococci isolates were susceptible to amoxicillin, with the exception of one S. mitis isolate. Remission 1 year after the end of treatment was recorded in 83%. One patient died of infection; eight patients had infections that failed to respond to treatment; and seven patients experienced relapse. Twenty patients (22%) had an unfavourable functional outcome, including 19 amputations and one arthrodesis. Five significant prognostic factors associated with an unfavourable clinical outcome were identified, including peripheral neuropathy (p 0.009), peripheral arterial disease (p 0.019), diabetes mellitus (p 0.031), location in the femur (p 0.0036), location in the foot (p 0.0475), osteitis without an orthopaedic device (p 0.041) and infection caused by S. dysgalactiae (p 0.020). The rate of poor outcomes remains high despite the low number of Streptococcus isolates resistant to antibiotics. Some prognostic factors, such as the presence of S. dysgalactiae, are associated with an unfavourable clinical outcome. Antibiotic regimens of streptococcal bone and joint infections are not standardized and need to be further investigated.

Bone and joint infections due to anaerobic bacteria: an analysis of 61 cases and review of the literature.

The diagnosis of anaerobic bone and joint infections (BJI) were underestimated before the advent of molecular identification and matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS). We report 61 cases of anaerobic infections based on our 4-year experience with the management of BJI. A total of 75% of cases were post-surgical infections, associated with osteosynthesis devices (65%). Early infections occurred in 27% of cases, delayed infections in 17.5% of cases, and late infections in 55% of cases. We recorded 36 species of 93 anaerobic strains using MALDI-TOF MS (91) and molecular methods (2). We identified 20 strains of Propionibacterium acnes, 13 of Finegoldia magna, six of Peptoniphilus asaccharolyticus, and six of P. harei. Polymicrobial infections occurred in 50 cases. Surgical treatment was performed in 93.5% of cases. The antibiotic treatments included amoxicillin (30%), amoxicillin-clavulanic acid (16%), metronidazole (30%), and clindamycin (26%). Hyperbaric oxygen therapy was used in 17 cases (28%). The relapse rate (27%) was associated with lower limbs localization (p = 0.001). P. acnes BJI was associated with shoulder (p = 0.019), vertebra (p = 0.021), and head flap localization (p = 0.011), and none of these cases relapsed (p = 0.007). F. magna BJI was associated with ankle localization (p = 0.014). Anaerobic BJI is typically considered as a post-surgical polymicrobial infection, and the management of this infection combines surgical and medical treatments. MALDI-TOF MS and molecular identification have improved diagnosis. Thus, physicians should be aware of the polymicrobial nature of anaerobic BJI to establish immediate broad-spectrum antibiotic treatment during the post-surgical period until accurate microbiological results have been obtained.

Categorical and coordinate spatial relations: fMRI evidence for hemispheric specialization.

Functional magnetic resonance imaging (fMRI) was applied to determine the involvement of the angular gyri in the processing of categorical and coordinate spatial relations. In a categorical task, subjects were asked to judge whether a dot was presented above or below a horizontal line. In a coordinate task, they were asked to judge whether or not the distance between the dot and the bar was within a reference distance. Results showed stronger activation of the left than of the right angular gyrus in the categorical task, and stronger activation, initially, of the right than of the left angular gyrus in the coordinate task. In addition, in the latter task, the involvement of the right angular gyrus decreased with practice while that of the left angular gyrus increased. These results are interpreted in terms of the development of new categorical representations with practice in the coordinate task.

Selection at implantation and longevity. A tentative theory.

Women enjoy a superior longevity, possibly at the price of a heavy loss of female conceptuses at an early stage of gestation. An immunological mechanism is proposed. A theory of selection at implantation is developed and generalized which leads to a new approach of longevity.

Sex differential of survival during perinatal period: an immunologic phenomenon?

The sex-differential early neonatal mortality experienced by a population of 27,243 neonates has been analyzed in relation to sex-related reproductive antecedents of their mothers. An association between the risk of dying of a neonate and the sex of previous pregnancies of its mother has been found: the risk decreases with a previous pregnancy of the same sex as the neonate, and increases with one of the opposite sex. Repeated pregnancies of same sex increase the phenomenon. An immunologic hypothesis has been formulated from these results: sex-differential survival of conceptuses during the perinatal period would be due to sex-differential conceptomaternal immunologic interactions. An advantage in survival of the female fetus results from these interactions in primiparous mothers. However, immunologic behavior of the mother is altered by previous contact with fetal antigens. Consequently sex-differential survival varies with sex-related antecedents of the gravida. Previous sensitization of the gravida by male pregnancy provides an advantage in survival for a subsequent male conceptus, and previous sensitization by female pregnancy provides an advantage in survival for a subsequent female conceptus.

Sex-differential placentation immunological interactions between male conceptus and gravida during normal pregnancy.

7,773 placentae of newborns were analyzed in order to test a hypothesis of specific immunological concepto-maternal interactions due to maleness and occurring during normal pregnancy. An association between placental weight of newborn male and the sex of conceptuses of previous pregnancies was found which supports the hypothesis. No such an association was found for female newborn. The confirmation of these results could open new avenues in the study of sex-differential survival of the conceptus throughout gestation.