Scandinavian Journal of Infectious Diseases
ISSN: 0036-5548 (Print) 1651-1980 (Online) Journal homepage: http://www.tandfonline.com/loi/infd19
Prosthetic hip joint infection caused by noncapsulated Haemophilus influenzae Bo Söderquist To cite this article: Bo Söderquist (2014) Prosthetic hip joint infection caused by noncapsulated Haemophilus influenzae, Scandinavian Journal of Infectious Diseases, 46:9, 665-668 To link to this article: http://dx.doi.org/10.3109/00365548.2014.920101
Published online: 11 Jun 2014.
Submit your article to this journal
Article views: 81
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=infd19 Download by: [Washington University in St Louis]
Date: 07 November 2015, At: 13:52
Scandinavian Journal of Infectious Diseases, 2014; 46: 665–668
CASE REPORT
Prosthetic hip joint infection caused by non-capsulated Haemophilus influenzae
Downloaded by [Washington University in St Louis] at 13:52 07 November 2015
BO SÖDERQUIST From the Departments of Laboratory Medicine, Clinical Microbiology, and Infectious Diseases, Örebro University Hospital, and Faculty of Medicine and Health, Örebro University, Örebro, Sweden
Abstract Haemophilus influenzae is rarely described as a causative agent of prosthetic joint infections. Here, a case of prosthetic hip joint infection caused by H. influenzae is reported. Treatment was successful, resulting in implant salvage, by debridement and antibiotic treatment with ciprofloxacin as monotherapy for 3 months.
Keywords: Haemophilus influenzae, prosthetic joint infection
Introduction Prosthetic joint infections (PJIs), although rare, are predominantly caused by staphylococci – both Staphylococcus aureus and coagulase-negative staphylococci [1]. However, a wide range of microorganisms have been reported as causes of PJIs. In these infections, the formation of biofilm by the microorganism is regarded as an important pathogenetic factor [2]. Treatment algorithms have been established for early postoperative and acute haematogenous infections, in which debridement with retention of stable prosthetic devices and treatment with antimicrobial agents with activity against biofilm-producing microorganisms are the cornerstones [3]. Gram-negative bacteria have recently been reported as playing an increasing role in PJIs [4–7] and are, as the staphylococci, able to produce biofilm. However, recent reports reviewing risk factors, treatment options, and outcomes of PJIs caused by Gram-negative microorganisms have focused on Enterobacteriaceae and non-fermentative Gramnegative rods such as Pseudomonas aeruginosa [4–7]. Haemophilus influenzae, especially type b (Hib), was the most common cause of native septic arthritis in young children before the introduction of the Hibconjugated vaccine. In addition, approximately 1%
of adult native septic arthritis cases are caused by H. influenzae, predominantly non-capsulated serotype b [8]. Despite this apparent predilection for bone and joint tissue, H. influenzae has very rarely been reported as a cause of PJI [9–12].
Case report A 25-y-old woman with a history of juvenile polyarthritis and diabetes mellitus type 1, presented a prosthetic hip joint infection. She had received bilateral shoulder prostheses as well as a right-side hip joint prosthesis in 1997. In addition, a peri-prosthetic fracture of the right femur in 2005 was treated with open reposition and osteosynthesis with screws, wires, and a plate. She worked in an office and had a normal functional status. Current medication was etanercept and corticosteroids. However, since the patient had become pregnant for the first time, the etanercept was discontinued. Unfortunately, the patient experienced a spontaneous abortion during week 18 that was interpreted as septic, since cultures from cervix discharge showed growth of H. influenzae. However, 4 days later the patient noted pain from the right hip and 1 day later the patient was admitted
Correspondence: B. Söderquist, Department of Clinical Microbiology, Örebro University Hospital, SE-70185 Örebro, Sweden. Tel: ⫹ 46 196021134. Fax: ⫹ 46 19127416. E-mail: [email protected] (Received 30 January 2014 ; accepted 23 April 2014 ) ISSN 0036-5548 print/ISSN 1651-1980 online © 2014 Informa Healthcare DOI: 10.3109/00365548.2014.920101
Downloaded by [Washington University in St Louis] at 13:52 07 November 2015
666
B. Söderquist
to hospital. At admission, C-reactive protein (CRP) was 129 mg/l (normal range ⬍ 4 mg/l). An ultrasound-guided arthrocentesis was performed. Following instillation of 5 ml of saline, 10 ml of purulent synovial fluid was aspirated. Empiric treatment was instituted with clindamycin 600 mg three times daily intravenously (due to a history of suspected allergy to penicillin). However, microscopic investigation revealed Gram-negative rods, and ciprofloxacin 400 mg twice daily intravenously was added the same day. The culture from the synovial fluid yielded H. influenzae. However, concomitant blood cultures were negative. Two days later, incision and debridement of the hip was performed. The plate and the screws were extracted, as well as most of the wires, although 2 of these were intact and adherent and were left in place. Pus was detected from the drill-holes and pus was present in the prosthetic joint cavity. Thorough soft tissue revision was performed including excision of the capsule, scar tissue, and necrotic infected tissue. Three perioperative tissue biopsies were taken but showed no growth. At discharge from the hospital 8 days later, the treatment was changed to ciprofloxacin 750 mg twice daily orally. The patient improved rapidly and the CRP normalized (⬍ 1 mg/l) within 1 month. However, the patient noted increasing symptoms from multiple joints, especially arthralgia, since the only anti-inflammatory treatment was corticosteroids. The patient was treated with ciprofloxacin orally for 3 months. At discontinuation of treatment the CRP was 23 mg/l and erythrocyte sedimentation rate (ESR) 44 mm/h. Follow-up for ⬎ 1 y has been uneventful. Microbiology H. influenzae was identified in accordance with routine diagnostic procedures at the Department of Laboratory Medicine, Clinical Microbiology, Örebro University Hospital and verified by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) using MALDI Biotyper software (Bruker Daltonik). The Swedish Institute for Infectious Disease Control further characterized the isolate as a serotype non-typeable (NT) biotype III H. influenzae strain. The 2 isolates obtained from the genital tract and from the synovial fluid were both beta-lactamase-positive (Cefinase disc test CEF-F; bioMérieux, Marcy l’Etoile, France), and antibiotic susceptibility testing performed in accordance with the European Committee on Antimicrobial Susceptibility Testing (EUCAST, http://www.eucast.org) by disk diffusion test (Oxoid, Basingstoke, UK) and Etest (bioMérieux) showed resistance to ampicillin/
amoxicillin and cefaclor; however the minimum inhibitory concentration (MIC) for the combination amoxicillin/clavulanic acid was 2 mg/l and for cefotaxime was 0.032 mg/l. Furthermore, the isolates were susceptible to trimethoprim–sulfamethoxazole and tetracycline. The MIC for ciprofloxacin was 0.016 mg/l. Discussion H. influenzae is a Gram-negative, pleomorphic, nonmotile rod that regularly colonizes exclusively the human pharynx and is transmitted by personto-person contact by droplets. H. influenzae may be part of the commensal flora of the upper respiratory tract of healthy individuals, especially healthy children. However, H. influenzae can spread directly from its reservoir in the oropharynx and cause focal infections such as acute otitis media, acute sinusitis, acute bronchitis, and pneumonia. In addition, H. influenzae can invade the bloodstream and thereby result in potential life-threatening invasive infections such as meningitis, epiglottis infections, bone and joint infections, and bacteraemia. Furthermore, H. influenzae also has the capacity to colonize the urogenital epithelium and cause urogenital infections [13]. Whether this is a normal niche for H. influenzae or whether it is transmitted by direct inoculation from contaminated hands or by oral sexual activity is unknown. The route of infection of PJIs is direct inoculation of bacteria into the wound during surgery, haematogenous spread, or transmission through neighbouring tissues. H. influenzae, as well as Haemophilus parainfluenzae, have very rarely been reported as microorganisms causing PJIs; a review of the literature identified only 4 available case reports of PJIs due to H. influenzae [9–12]. The route of transmission in these previously reported cases was most probably haematogenous, due to the habit of the microorganism and the history of the cases. In the present case, a septic abortion preceded the infection of the prosthetic devices. The haematogenous route of spread was thus the most plausible, and the antibiotic susceptibility pattern strongly indicated that the same strain was present in cultures from the cervix discharge, the blood cultures, and the perioperative tissue biopsies from the hip joint. H. influenzae produces 1 of 6 distinct capsular polysaccharides (serotypes a–f) or may be noncapsulated. Systemic infections are usually caused by capsular type b strains. Following the introduction of the Hib vaccine, invasive disease caused by H. influenzae will probably be restricted to predominantly non-capsulated H. influenzae, at least among
Downloaded by [Washington University in St Louis] at 13:52 07 November 2015
Prosthetic hip joint infection by H. influenzae children and young adults. A relative increase in the incidence of non-capsulated H. influenzae could be expected. However, among adults, invasive infections caused by H. influenzae could still be expected to be caused by Hib. The present case was caused by a non-capsulated H. influenzae, as was the case reported by Le Quellec et al. [12] in 2013, where the isolate was further characterized as a non-capsulated biotype II H. influenzae strain. Unfortunately no detailed information is available for the isolates in the other previous case reports [9–11]. The capsule is an important virulence factor, which is anti-phagocytic and counteracts opsonization that will be lacking in these cases. However, non-typeable H. influenzae has been reported to form biofilm in vitro [14], which may contribute to their ability to cause foreign body infections, such as PJIs, by promoting adherence and hindering the delivery of antibiotics to the focal infectious site. In the previously reported cases, a 1-stage exchange procedure was performed in 1 case [12], and in the 3 other cases [9–11] the prosthetic devices were left in place (in 1 case due to the refusal of the patient to have any implant components removed). All reported cases underwent debridement. In early postoperative or acute haematogenous PJIs caused by Gram-negative bacteria (duration of symptoms ⱕ 3 weeks), the same strategy, i.e. debridement and revision but retention of stable prosthetic devices and treatment with antibiotics, is, as in PJIs caused by staphylococci [3], probably crucial for a favourable outcome [4,5,15,16]. Initial intravenous therapy with cephalosporins or carbapenems in order to reduce bacterial load may be instituted subsequently, followed by long-term oral treatment with an antimicrobial agent active against stationary growing bacteria, preferentially fluoroquinolones. Therefore, cell wall active antibiotics such as beta-lactams should not be considered and the discussion regarding beta-lactamase-positive and amoxicillin–clavulanic acid-resistant (BLPACR) H. influenzae is not relevant in this context. However, resistance to fluoroquinolones in Gram-negative bacteria is associated with treatment failure, requiring implant removal [4]. In addition, both clinical observation and experimental results from a foreign-body animal model have shown treatment failure when using co-trimoxazole for implant-related infections due to Gram-negative bacteria [17]. This is contrary to the finding that co-trimoxazole is efficient for the long-term oral antibiotic therapy of PJIs caused by staphylococci [18]. The present patient was treated successfully with 3 months of ciprofloxacin as monotherapy following discharge from the hospital. The recommended duration of treatment for hip arthroplasty PJIs is 3 months
667
[3], but a shorter course, i.e. 2 months, may be appropriate for prosthetic hip infections [19]. In the previous case reports, the long-term follow-up antibiotic treatment regimens were ertapenem subcutaneously and ofloxacin orally for 3 months [12], oral levofloxacin for 1 y [11], 6 weeks of intravenous ampicillin followed by oral amoxicillin (length of course not defined) [10], and finally probably only 2 weeks of intravenously administered ampicillin in 1 case [9]. Long-term follow-up was favourable in the reported cases. The present patient had ongoing treatment with etanercept and corticosteroids due to juvenile polyarthritis. Of note, 3 of the previously reported patients [10–12] also presented concomitant autoimmune disorders such as rheumatoid arthritis and systemic lupus erythematosus, which may indicate a risk factor. In conclusion, an early or haematogenous PJI caused by H. influenzae with a short duration of clinical symptoms should be treated promptly with debridement and appropriate intravenous antibiotics, followed by oral monotherapy with fluoroquinolones. Declaration of interest: Transparency declaration Bo Söderquist has been a consultant for Pfizer and Janssen-Cilag. The author alone is responsible for the content and writing of the paper.
References [1] Stefánsdóttir A, Johansson D, Knutson K, Lidgren L, Robertsson O. Microbiology of the infected knee arthroplasty: report from the Swedish Knee Arthroplasty Register on 426 surgically revised cases. Scand J Infect Dis 2009;41: 831–40. [2] Zimmerli W, Moser C. Pathogenesis and treatment concepts of orthopaedic biofilm infections. FEMS Immunol Med Microbiol 2012;65:158–68. [3] Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med 2004;351:1645–54. [4] Martínez-Pastor JC, Muñoz-Mahamud E, Vilchez F, GarcíaRamiro S, Bori G, Sierra J, et al. Outcome of acute prosthetic joint infections due to Gram-negative bacilli treated with open debridement and retention of the prosthesis. Antimicrob Agents Chemother 2009;53:4772–7. [5] Aboltins CA, Dowsey MM, Buising KL, Peel TN, Daffy JR, Choong PF, et al. Gram-negative prosthetic joint infection treated with debridement, prosthesis retention and antibiotic regimens including a fluoroquinolone. Clin Microbiol Infect 2011;17:862–7. [6] Zmistowski B, Fedorka CJ, Sheehan E, Deirmengian G, Austin MS, Parvizi J. Prosthetic joint infection caused by Gram-negative organisms. J Arthroplasty 2011;26:104–8. [7] Jaén N, Martínez-Pastor JC, Muñoz-Mahamud E, GarcíaRamiro S, Bosch J, Mensa J, Soriano A. Long-term outcome of acute prosthetic joint infections due to Gram-negative bacilli treated with retention of prosthesis. Rev Esp Quimioter 2012;25:194–8.
Downloaded by [Washington University in St Louis] at 13:52 07 November 2015
668
B. Söderquist
[8] Ryan MJ, Kavanagh R, Wall PG, Hazleman BL. Bacterial joint infections in England and Wales: analysis of bacterial isolates over a four year period. Br J Rheumatol 1997;36: 370–3. [9] Limbird TJ. Hemophilus influenzae infection of a total hip arthroplasty. Clin Orthop Relat Res 1985;199:182–4. [10] Borenstein DG, Simon GL. Hemophilus influenzae septic arthritis in adults. A report of four cases and a review of the literature. Medicine (Baltimore) 1986;65:191–201. [11] Bezwada HP, Nazarian DG, Booth RE Jr. Haemophilus influenzae infection complicating a total knee arthroplasty. Clin Orthop Relat Res 2002;402:202–5. [12] Le Quellec S, Gaillot O, Chotel F, Freydière AM, Laurent F, Vandenesch F, Doléans-Jordheim A. Septic arthritis caused by noncapsulated Haemophilus influenzae. J Clin Microbiol 2013;51:1970–2. [13] Albritton WL, Brunton JL, Meier M, Bowman MN, Slaney LA. Haemophilus influenzae: comparison of respiratory tract isolates with genitourinary tract isolates. J Clin Microbiol 1982;16:826–31.
[14] Hsieh PH, Lee MS, Hsu KY, Chang YH, Shih HN, Ueng SW. Gram-negative prosthetic joint infections: risk factors and outcome of treatment. Clin Infect Dis 2009;49:1036–43. [15] Murphy TF, Kirkham C. Biofilm formation by nontypeable Haemophilus influenzae: strain variability, outer membrane antigen expression and role of pili. BMC Microbiol 2002; 2:7. [16] Uckay I, Bernard L. Gram-negative versus Gram-positive prosthetic joint infections. Clin Infect Dis 2010;50:795. [17] Sendi P, Zimmerli W. Antimicrobial treatment concepts for orthopaedic device-related infection. Clin Microbiol Infect 2012;18:1176–84. [18] Stein A, Bataille JF, Drancourt M, Curvale G, Argenson JN, Groulier P, Raoult D. Ambulatory treatment of multidrugresistant Staphylococcus-infected orthopedic implants with high-dose oral co-trimoxazole (trimethoprim–sulfamethoxazole). Antimicrob Agents Chemother 1998;42:3086–91. [19] Puhto AP, Puhto T, Syrjala H. Short-course antibiotics for prosthetic joint infections treated with prosthesis retention. Clin Microbiol Infect 2012;18:1143–8.
ISSN: 0036-5548 (Print) 1651-1980 (Online) Journal homepage: http://www.tandfonline.com/loi/infd19
Prosthetic hip joint infection caused by noncapsulated Haemophilus influenzae Bo Söderquist To cite this article: Bo Söderquist (2014) Prosthetic hip joint infection caused by noncapsulated Haemophilus influenzae, Scandinavian Journal of Infectious Diseases, 46:9, 665-668 To link to this article: http://dx.doi.org/10.3109/00365548.2014.920101
Published online: 11 Jun 2014.
Submit your article to this journal
Article views: 81
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=infd19 Download by: [Washington University in St Louis]
Date: 07 November 2015, At: 13:52
Scandinavian Journal of Infectious Diseases, 2014; 46: 665–668
CASE REPORT
Prosthetic hip joint infection caused by non-capsulated Haemophilus influenzae
Downloaded by [Washington University in St Louis] at 13:52 07 November 2015
BO SÖDERQUIST From the Departments of Laboratory Medicine, Clinical Microbiology, and Infectious Diseases, Örebro University Hospital, and Faculty of Medicine and Health, Örebro University, Örebro, Sweden
Abstract Haemophilus influenzae is rarely described as a causative agent of prosthetic joint infections. Here, a case of prosthetic hip joint infection caused by H. influenzae is reported. Treatment was successful, resulting in implant salvage, by debridement and antibiotic treatment with ciprofloxacin as monotherapy for 3 months.
Keywords: Haemophilus influenzae, prosthetic joint infection
Introduction Prosthetic joint infections (PJIs), although rare, are predominantly caused by staphylococci – both Staphylococcus aureus and coagulase-negative staphylococci [1]. However, a wide range of microorganisms have been reported as causes of PJIs. In these infections, the formation of biofilm by the microorganism is regarded as an important pathogenetic factor [2]. Treatment algorithms have been established for early postoperative and acute haematogenous infections, in which debridement with retention of stable prosthetic devices and treatment with antimicrobial agents with activity against biofilm-producing microorganisms are the cornerstones [3]. Gram-negative bacteria have recently been reported as playing an increasing role in PJIs [4–7] and are, as the staphylococci, able to produce biofilm. However, recent reports reviewing risk factors, treatment options, and outcomes of PJIs caused by Gram-negative microorganisms have focused on Enterobacteriaceae and non-fermentative Gramnegative rods such as Pseudomonas aeruginosa [4–7]. Haemophilus influenzae, especially type b (Hib), was the most common cause of native septic arthritis in young children before the introduction of the Hibconjugated vaccine. In addition, approximately 1%
of adult native septic arthritis cases are caused by H. influenzae, predominantly non-capsulated serotype b [8]. Despite this apparent predilection for bone and joint tissue, H. influenzae has very rarely been reported as a cause of PJI [9–12].
Case report A 25-y-old woman with a history of juvenile polyarthritis and diabetes mellitus type 1, presented a prosthetic hip joint infection. She had received bilateral shoulder prostheses as well as a right-side hip joint prosthesis in 1997. In addition, a peri-prosthetic fracture of the right femur in 2005 was treated with open reposition and osteosynthesis with screws, wires, and a plate. She worked in an office and had a normal functional status. Current medication was etanercept and corticosteroids. However, since the patient had become pregnant for the first time, the etanercept was discontinued. Unfortunately, the patient experienced a spontaneous abortion during week 18 that was interpreted as septic, since cultures from cervix discharge showed growth of H. influenzae. However, 4 days later the patient noted pain from the right hip and 1 day later the patient was admitted
Correspondence: B. Söderquist, Department of Clinical Microbiology, Örebro University Hospital, SE-70185 Örebro, Sweden. Tel: ⫹ 46 196021134. Fax: ⫹ 46 19127416. E-mail: [email protected] (Received 30 January 2014 ; accepted 23 April 2014 ) ISSN 0036-5548 print/ISSN 1651-1980 online © 2014 Informa Healthcare DOI: 10.3109/00365548.2014.920101
Downloaded by [Washington University in St Louis] at 13:52 07 November 2015
666
B. Söderquist
to hospital. At admission, C-reactive protein (CRP) was 129 mg/l (normal range ⬍ 4 mg/l). An ultrasound-guided arthrocentesis was performed. Following instillation of 5 ml of saline, 10 ml of purulent synovial fluid was aspirated. Empiric treatment was instituted with clindamycin 600 mg three times daily intravenously (due to a history of suspected allergy to penicillin). However, microscopic investigation revealed Gram-negative rods, and ciprofloxacin 400 mg twice daily intravenously was added the same day. The culture from the synovial fluid yielded H. influenzae. However, concomitant blood cultures were negative. Two days later, incision and debridement of the hip was performed. The plate and the screws were extracted, as well as most of the wires, although 2 of these were intact and adherent and were left in place. Pus was detected from the drill-holes and pus was present in the prosthetic joint cavity. Thorough soft tissue revision was performed including excision of the capsule, scar tissue, and necrotic infected tissue. Three perioperative tissue biopsies were taken but showed no growth. At discharge from the hospital 8 days later, the treatment was changed to ciprofloxacin 750 mg twice daily orally. The patient improved rapidly and the CRP normalized (⬍ 1 mg/l) within 1 month. However, the patient noted increasing symptoms from multiple joints, especially arthralgia, since the only anti-inflammatory treatment was corticosteroids. The patient was treated with ciprofloxacin orally for 3 months. At discontinuation of treatment the CRP was 23 mg/l and erythrocyte sedimentation rate (ESR) 44 mm/h. Follow-up for ⬎ 1 y has been uneventful. Microbiology H. influenzae was identified in accordance with routine diagnostic procedures at the Department of Laboratory Medicine, Clinical Microbiology, Örebro University Hospital and verified by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) using MALDI Biotyper software (Bruker Daltonik). The Swedish Institute for Infectious Disease Control further characterized the isolate as a serotype non-typeable (NT) biotype III H. influenzae strain. The 2 isolates obtained from the genital tract and from the synovial fluid were both beta-lactamase-positive (Cefinase disc test CEF-F; bioMérieux, Marcy l’Etoile, France), and antibiotic susceptibility testing performed in accordance with the European Committee on Antimicrobial Susceptibility Testing (EUCAST, http://www.eucast.org) by disk diffusion test (Oxoid, Basingstoke, UK) and Etest (bioMérieux) showed resistance to ampicillin/
amoxicillin and cefaclor; however the minimum inhibitory concentration (MIC) for the combination amoxicillin/clavulanic acid was 2 mg/l and for cefotaxime was 0.032 mg/l. Furthermore, the isolates were susceptible to trimethoprim–sulfamethoxazole and tetracycline. The MIC for ciprofloxacin was 0.016 mg/l. Discussion H. influenzae is a Gram-negative, pleomorphic, nonmotile rod that regularly colonizes exclusively the human pharynx and is transmitted by personto-person contact by droplets. H. influenzae may be part of the commensal flora of the upper respiratory tract of healthy individuals, especially healthy children. However, H. influenzae can spread directly from its reservoir in the oropharynx and cause focal infections such as acute otitis media, acute sinusitis, acute bronchitis, and pneumonia. In addition, H. influenzae can invade the bloodstream and thereby result in potential life-threatening invasive infections such as meningitis, epiglottis infections, bone and joint infections, and bacteraemia. Furthermore, H. influenzae also has the capacity to colonize the urogenital epithelium and cause urogenital infections [13]. Whether this is a normal niche for H. influenzae or whether it is transmitted by direct inoculation from contaminated hands or by oral sexual activity is unknown. The route of infection of PJIs is direct inoculation of bacteria into the wound during surgery, haematogenous spread, or transmission through neighbouring tissues. H. influenzae, as well as Haemophilus parainfluenzae, have very rarely been reported as microorganisms causing PJIs; a review of the literature identified only 4 available case reports of PJIs due to H. influenzae [9–12]. The route of transmission in these previously reported cases was most probably haematogenous, due to the habit of the microorganism and the history of the cases. In the present case, a septic abortion preceded the infection of the prosthetic devices. The haematogenous route of spread was thus the most plausible, and the antibiotic susceptibility pattern strongly indicated that the same strain was present in cultures from the cervix discharge, the blood cultures, and the perioperative tissue biopsies from the hip joint. H. influenzae produces 1 of 6 distinct capsular polysaccharides (serotypes a–f) or may be noncapsulated. Systemic infections are usually caused by capsular type b strains. Following the introduction of the Hib vaccine, invasive disease caused by H. influenzae will probably be restricted to predominantly non-capsulated H. influenzae, at least among
Downloaded by [Washington University in St Louis] at 13:52 07 November 2015
Prosthetic hip joint infection by H. influenzae children and young adults. A relative increase in the incidence of non-capsulated H. influenzae could be expected. However, among adults, invasive infections caused by H. influenzae could still be expected to be caused by Hib. The present case was caused by a non-capsulated H. influenzae, as was the case reported by Le Quellec et al. [12] in 2013, where the isolate was further characterized as a non-capsulated biotype II H. influenzae strain. Unfortunately no detailed information is available for the isolates in the other previous case reports [9–11]. The capsule is an important virulence factor, which is anti-phagocytic and counteracts opsonization that will be lacking in these cases. However, non-typeable H. influenzae has been reported to form biofilm in vitro [14], which may contribute to their ability to cause foreign body infections, such as PJIs, by promoting adherence and hindering the delivery of antibiotics to the focal infectious site. In the previously reported cases, a 1-stage exchange procedure was performed in 1 case [12], and in the 3 other cases [9–11] the prosthetic devices were left in place (in 1 case due to the refusal of the patient to have any implant components removed). All reported cases underwent debridement. In early postoperative or acute haematogenous PJIs caused by Gram-negative bacteria (duration of symptoms ⱕ 3 weeks), the same strategy, i.e. debridement and revision but retention of stable prosthetic devices and treatment with antibiotics, is, as in PJIs caused by staphylococci [3], probably crucial for a favourable outcome [4,5,15,16]. Initial intravenous therapy with cephalosporins or carbapenems in order to reduce bacterial load may be instituted subsequently, followed by long-term oral treatment with an antimicrobial agent active against stationary growing bacteria, preferentially fluoroquinolones. Therefore, cell wall active antibiotics such as beta-lactams should not be considered and the discussion regarding beta-lactamase-positive and amoxicillin–clavulanic acid-resistant (BLPACR) H. influenzae is not relevant in this context. However, resistance to fluoroquinolones in Gram-negative bacteria is associated with treatment failure, requiring implant removal [4]. In addition, both clinical observation and experimental results from a foreign-body animal model have shown treatment failure when using co-trimoxazole for implant-related infections due to Gram-negative bacteria [17]. This is contrary to the finding that co-trimoxazole is efficient for the long-term oral antibiotic therapy of PJIs caused by staphylococci [18]. The present patient was treated successfully with 3 months of ciprofloxacin as monotherapy following discharge from the hospital. The recommended duration of treatment for hip arthroplasty PJIs is 3 months
667
[3], but a shorter course, i.e. 2 months, may be appropriate for prosthetic hip infections [19]. In the previous case reports, the long-term follow-up antibiotic treatment regimens were ertapenem subcutaneously and ofloxacin orally for 3 months [12], oral levofloxacin for 1 y [11], 6 weeks of intravenous ampicillin followed by oral amoxicillin (length of course not defined) [10], and finally probably only 2 weeks of intravenously administered ampicillin in 1 case [9]. Long-term follow-up was favourable in the reported cases. The present patient had ongoing treatment with etanercept and corticosteroids due to juvenile polyarthritis. Of note, 3 of the previously reported patients [10–12] also presented concomitant autoimmune disorders such as rheumatoid arthritis and systemic lupus erythematosus, which may indicate a risk factor. In conclusion, an early or haematogenous PJI caused by H. influenzae with a short duration of clinical symptoms should be treated promptly with debridement and appropriate intravenous antibiotics, followed by oral monotherapy with fluoroquinolones. Declaration of interest: Transparency declaration Bo Söderquist has been a consultant for Pfizer and Janssen-Cilag. The author alone is responsible for the content and writing of the paper.
References [1] Stefánsdóttir A, Johansson D, Knutson K, Lidgren L, Robertsson O. Microbiology of the infected knee arthroplasty: report from the Swedish Knee Arthroplasty Register on 426 surgically revised cases. Scand J Infect Dis 2009;41: 831–40. [2] Zimmerli W, Moser C. Pathogenesis and treatment concepts of orthopaedic biofilm infections. FEMS Immunol Med Microbiol 2012;65:158–68. [3] Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med 2004;351:1645–54. [4] Martínez-Pastor JC, Muñoz-Mahamud E, Vilchez F, GarcíaRamiro S, Bori G, Sierra J, et al. Outcome of acute prosthetic joint infections due to Gram-negative bacilli treated with open debridement and retention of the prosthesis. Antimicrob Agents Chemother 2009;53:4772–7. [5] Aboltins CA, Dowsey MM, Buising KL, Peel TN, Daffy JR, Choong PF, et al. Gram-negative prosthetic joint infection treated with debridement, prosthesis retention and antibiotic regimens including a fluoroquinolone. Clin Microbiol Infect 2011;17:862–7. [6] Zmistowski B, Fedorka CJ, Sheehan E, Deirmengian G, Austin MS, Parvizi J. Prosthetic joint infection caused by Gram-negative organisms. J Arthroplasty 2011;26:104–8. [7] Jaén N, Martínez-Pastor JC, Muñoz-Mahamud E, GarcíaRamiro S, Bosch J, Mensa J, Soriano A. Long-term outcome of acute prosthetic joint infections due to Gram-negative bacilli treated with retention of prosthesis. Rev Esp Quimioter 2012;25:194–8.
Downloaded by [Washington University in St Louis] at 13:52 07 November 2015
668
B. Söderquist
[8] Ryan MJ, Kavanagh R, Wall PG, Hazleman BL. Bacterial joint infections in England and Wales: analysis of bacterial isolates over a four year period. Br J Rheumatol 1997;36: 370–3. [9] Limbird TJ. Hemophilus influenzae infection of a total hip arthroplasty. Clin Orthop Relat Res 1985;199:182–4. [10] Borenstein DG, Simon GL. Hemophilus influenzae septic arthritis in adults. A report of four cases and a review of the literature. Medicine (Baltimore) 1986;65:191–201. [11] Bezwada HP, Nazarian DG, Booth RE Jr. Haemophilus influenzae infection complicating a total knee arthroplasty. Clin Orthop Relat Res 2002;402:202–5. [12] Le Quellec S, Gaillot O, Chotel F, Freydière AM, Laurent F, Vandenesch F, Doléans-Jordheim A. Septic arthritis caused by noncapsulated Haemophilus influenzae. J Clin Microbiol 2013;51:1970–2. [13] Albritton WL, Brunton JL, Meier M, Bowman MN, Slaney LA. Haemophilus influenzae: comparison of respiratory tract isolates with genitourinary tract isolates. J Clin Microbiol 1982;16:826–31.
[14] Hsieh PH, Lee MS, Hsu KY, Chang YH, Shih HN, Ueng SW. Gram-negative prosthetic joint infections: risk factors and outcome of treatment. Clin Infect Dis 2009;49:1036–43. [15] Murphy TF, Kirkham C. Biofilm formation by nontypeable Haemophilus influenzae: strain variability, outer membrane antigen expression and role of pili. BMC Microbiol 2002; 2:7. [16] Uckay I, Bernard L. Gram-negative versus Gram-positive prosthetic joint infections. Clin Infect Dis 2010;50:795. [17] Sendi P, Zimmerli W. Antimicrobial treatment concepts for orthopaedic device-related infection. Clin Microbiol Infect 2012;18:1176–84. [18] Stein A, Bataille JF, Drancourt M, Curvale G, Argenson JN, Groulier P, Raoult D. Ambulatory treatment of multidrugresistant Staphylococcus-infected orthopedic implants with high-dose oral co-trimoxazole (trimethoprim–sulfamethoxazole). Antimicrob Agents Chemother 1998;42:3086–91. [19] Puhto AP, Puhto T, Syrjala H. Short-course antibiotics for prosthetic joint infections treated with prosthesis retention. Clin Microbiol Infect 2012;18:1143–8.
