Validation of the diagnostic criteria of the consensus definition of fracture-related infection

Onsea, Jolien; Lieshout, Esther M.M. Van; Zalavras, Charalampos G.; Sliepen, Jonathan; Depypere, Maarten; Noppe, Nathalie; Ferguson, Jamie; Verhofstad, Michael H.J.; Govaert, Geertje A M; IJpma, Frank F. A.; McNally, Martin; Metsemakers, Willem‐Jan

doi:10.1016/j.injury.2022.03.024

Cited by 47 publications

(45 citation statements)

References 30 publications

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“…Another explanation for the difference in infection rates could be the use of arbitrary definitions of infection (i.e., deep infection) in the studies included in this systematic review. Using an inadequate definition for FRI risks underestimating the actual number of infections, thereby resulting in misleading conclusions [34] .…”

Section: Discussionmentioning

confidence: 99%

Fracture-related infection of the patella: Treatment options and outcome

Boeckxstaens

Hoekstra

Depypere

et al. 2022

Injury

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Section: Discussionmentioning

confidence: 99%

Fracture-related infection of the patella: Treatment options and outcome

Boeckxstaens

Hoekstra

Depypere

et al. 2022

Injury

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“…Single positive culture tests were considered only when a virulent pathogen was isolated. Virulent pathogens were defined a priori as Gram negative bacilli (GNB), Staphylococcus aureus, Staphylococcus lugdunensis , enterococci, beta-hemolytic streptococci, Streptococcus anginosus group (previously milleri group streptococci), Streptococcus pneumoniae and Candida spp ( Onsea et al., 2022 ). Single positive cultures with non-virulent pathogens were not further evaluated as they were seen as contaminants.…”

Section: Methodsmentioning

confidence: 99%

The Microbiological Etiology of Fracture-Related Infection

Depypere

Sliepen

Onsea

et al. 2022

Front. Cell. Infect. Microbiol.

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PurposeFracture-related infection (FRI) is an important complication related to orthopaedic trauma. Although the scientific interest with respect to the diagnosis and treatment of FRI is increasing, data on the microbiological epidemiology remains limited. Therefore, the primary aim of this study was to evaluate the microbiological epidemiology related to FRI, including the association with clinical symptoms and antimicrobial susceptibility data. The secondary aim was to analyze whether there was a relationship between the time to onset of infection and the microbiological etiology of FRI.MethodsFRI patients treated at the University Hospitals of Leuven, Belgium, between January 1st 2015 and November 24th 2019 were evaluated retrospectively. The microbiological etiology and antimicrobial susceptibility data were analyzed. Patients were classified as having an early (<2 weeks after implantation), delayed (2-10 weeks) or late-onset (> 10 weeks) FRI.ResultsOne hundred ninety-one patients with 194 FRIs, most frequently involving the tibia (23.7%) and femur (18.6%), were included. Staphylococcus aureus was the most frequently isolated pathogen, regardless of time to onset (n=61; 31.4%), followed by S. epidermidis (n=50; 25.8%) and non-epidermidis coagulase-negative staphylococci (n=35; 18.0%). Polymicrobial infections (n=49; 25.3%), mainly involving Gram negative bacilli (GNB) (n=32; 65.3%), were less common than monomicrobial infections (n=138; 71.1%). Virulent pathogens in monomicrobial FRIs were more likely to cause pus or purulent discharge (n=45;54.9%; p=0.002) and fistulas (n=21;25.6%; p=0.030). Susceptibility to piperacillin/tazobactam for GNB was 75.9%. Vancomycin covered 100% of Gram positive cocci.ConclusionThis study revealed that in early FRIs, polymicrobial infections and infections including Enterobacterales and enterococcal species were more frequent. A time-based FRI classification is not meaningful to estimate the microbiological epidemiology and cannot be used to guide empiric antibiotic therapy. Large multicenter prospective studies are necessary to gain more insight into the added value of (broad) empirical antibiotic therapy.

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Section: Introductionmentioning

confidence: 99%

“…The confirmatory criteria were recently validated in a large retrospective cohort study (Onsea et al, 2022). The presence of at least one confirmatory criterion was associated with a sensitivity of 97.5 % and a specificity of 100 % (Onsea et al, 2022). While the diagnosis of infection is thus clear in the presence of clinical confirmatory criteria and treatment can immediately be started, this is less evident in the absence of these criteria.…”

Section: Introductionmentioning

confidence: 99%

Diagnosis of fracture-related infection in patients without clinical confirmatory criteria: an international retrospective cohort study

Vanvelk

Lieshout

Onsea

et al. 2023

J. Bone Joint Infect.

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Abstract. Background: fracture-related infection (FRI) remains a serious complication in orthopedic trauma. To standardize daily clinical practice, a consensus definition was established, based on confirmatory and suggestive criteria. In the presence of clinical confirmatory criteria, the diagnosis of an FRI is evident, and treatment can be started. However, if these criteria are absent, the decision to surgically collect deep tissue cultures can only be based on suggestive criteria. The primary study aim was to characterize the subpopulation of FRI patients presenting without clinical confirmatory criteria (fistula, sinus, wound breakdown, purulent wound drainage or presence of pus during surgery). The secondary aims were to describe the prevalence of the diagnostic criteria for FRI and present the microbiological characteristics, both for the entire FRI population. Methods: a multicenter, retrospective cohort study was performed, reporting the demographic, clinical and microbiological characteristics of 609 patients (with 613 fractures) who were treated for FRI based on the recommendations of a multidisciplinary team. Patients were divided in three groups, including the total population and two subgroups of patients presenting with or without clinical confirmatory criteria. Results: clinical and microbiological confirmatory criteria were present in 77 % and 87 % of the included fractures, respectively. Of patients, 23 % presented without clinical confirmatory criteria, and they mostly displayed one (31 %) or two (23 %) suggestive clinical criteria (redness, swelling, warmth, pain, fever, new-onset joint effusion, persisting/increasing/new-onset wound drainage). The prevalence of any suggestive clinical, radiological or laboratory criteria in this subgroup was 85 %, 55 % and 97 %, respectively. Most infections were monomicrobial (64 %) and caused by Staphylococcus aureus. Conclusion: clinical confirmatory criteria were absent in 23 % of the FRIs. In these cases, the decision to operatively collect deep tissue cultures was based on clinical, radiological and laboratory suggestive criteria. The combined use of these criteria should guide physicians in the management pathway of FRI. Further research is needed to provide guidelines on the decision to proceed with surgery when only these suggestive criteria are present.

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Validation of the diagnostic criteria of the consensus definition of fracture-related infection

Cited by 47 publications

References 30 publications

Fracture-related infection of the patella: Treatment options and outcome

Fracture-related infection of the patella: Treatment options and outcome

The Microbiological Etiology of Fracture-Related Infection

Diagnosis of fracture-related infection in patients without clinical confirmatory criteria: an international retrospective cohort study

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