Chronic septic arthritis and osteomyelitis in a prosthetic knee joint due toClostridium difficile

Abstract

A case of chronic septic arthritis and osteomyelitis in a prosthetic knee joint due to Clostridium difficile is reported. A knee prosthesis was installed in a 16-year-old boy for surgical treatment of an osteosarcoma of the femur. Later, the patient suffered a traumatic closed fracture of his patella, and a sterile fluid was aspirated. One month later, the joint displayed inflammation. Culture of the articular fluid yielded a nontoxigenic Clostridium difficile strain. Despite several attempts using conservative medical treatment with penicillins and ornidazole, Clostridium difficile strains with the same antibiotic susceptibility pattern were repeatedly isolated from the joint over an eight-month period. The foreign material was then ablated, and finally, the patient's leg was amputated one year after Clostridium difficile was first isolated. The possible sources of contamination in our case and other reported cases of extraintestinal infection due to Clostridium difficile are discussed.

Anaerobic prosthetic joint infection

“…Other case reports have indicated the presence of gas surrounding the prosthesis [13,15,19,77,78]; this was most commonly seen in cases of C. perfringens and C. cadaveris PJI. No specific site of involvement appears to be uniquely associated with Clostridium PJI, as there are cases reported involving hip, knee and shoulder arthroplasties [14,35,75]. A few case reports have outlined the presence of concomitant microorganisms associated with these infections, including coagulase negative Staphylococcus species [14,33], as well as Enterobacter species [33].…”

“…One case of C. cadaveris PJI was managed successfully with prosthesis retention and treatment with parenteral clindamycin, followed by suppression with oral clindamycin [13]. From a surgical standpoint, the majority of reported cases have been treated with resection arthroplasty, with or without reimplantation [11,14,15,19,33]; often, complete removal of the prosthesis and even amputation were necessary [14,35,74,75]. Some authors recommended avoiding one-stage exchange procedures [15].…”

“…There are also reports of PJI due of Clostridium septicum and Clostridium cadaveris. Clostridium PJI tends to present early, within three months after the initial implantation of hardware [12,14,33,74], but may also present later on [11,35,75]. There are a limited number of case reports outlining the clinical features of Clostridium PJI; localized tenderness, redness, swelling and warmth were present in the majority of patients [11e14, 19,32,33,35,74e76].…”

Clostridium difficile ribotype 078 cultured from post-surgical non-healing wound in a patient carrying ribotype 014 in the intestinal tract

“…In a recent review encompassing 59 patients with extra-intestinal C. difficile infection (CDI) (Bedimo and Weinsten 2003), three major forms of clinical manifestation were described: bacteraemia with or without focal infection (Bedimo and Weinsten 2003;Feldman et al 1995;Libby and Bearman 2009;Lee et al 2010;Gerard et al 1989;Hemminger et al 2011;Choi et al 2013), intra-abdominal infection, and extraabdominal abscesses (Bedimo and Weinsten 2003), such as a splenic abscess (Stieglbauer et al 1995;Studemeister et al 1987;Saginur et al 1983) and a brain abscess (Gravisse et al 2003). C. difficile has also been associated with reactive arthritis (Loffler et al 2004;Birnbaum et al 2008;Prati et al 2010), osteomyelitis (Al-Najjar et al 2013;Pron et al 1995;Riley and Karthigasu 1982), and prosthetic shoulder and knee joint infection (Pron et al 1995;Ranganath and Midturi 2013;McCarthy and Stingemore 1999). Necrotizing fasciitis (Bhargava et al 2000;Duburcq et al 2013) and posttraumatic wound infections with C. difficile have been reported in two case reports (Deptula et al 2009;Urbán et al 2010).…”

Campylobacter Prosthetic Joint Infection

“…As illustrated in the report by Prendki et al of two postoperative Campylobacter PJI cases occurring after recent gastroenteritis (9), consideration should be given to postponing elective arthroplasty surgery in patients who have had a recent episode of bacterial gastroenteritis. PJIs caused by non-Campylobacter enteric pathogens have included Yersinia enterocolitica (32)(33)(34), Salmonella species (over 20 cases reported) (35), and Clostridium difficile (36)(37)(38)(39). Although current treatment recommendations for campylobacteriosis limit treatment to those with severe illness, protracted symptoms (Ͼ1 week), and the immunocompromised (40,41), based on the findings reported herein, treatment might also be considered for those with prosthetic joints because patients with prosthetic joints may have a predilection to developing PJI after what may initially seem like an innocuous gastrointestinal illness.…”