Artritis protésica por Propienibacterium acnes
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Artritis protésica por Propienibacterium acnes
- 2. MOTIVO DE INGRESO Varón 67 años que ingresa de forma programada para realizar 2º tiempo IQ protésica de hombro. ANTECEDENTES PATOL. No RAMC DM tipo II Hipercolesterolemia Hernia de hiato Adenocarcinoma de próstata Incontinencia urinaria genuina de esfuerzo post-cirugía radical
- 3. PRÓTESIS DE LA CABEZA HUMERAL LIMITACIÓN FUNCIONAL EN LA ABDUCCIÓN ARTROSCOPIA CON BIOPSIA Exploración gammagráfica SIN EVIDENCIA DE INFECCIÓN ACTIVA PERIPROTÉSICA. Los hallazgos descritos en el estudio son compatibles con un proceso inflamatorio/degenerativo articular. HISTORIA TRAUMATOLÓGICA
- 4. BUENA EVOLUCIÓN S.epidermidis en 6/8 muestras intraoperatorias. NO Propionibacterium spp. ARTROSCOPIA CON BIOPSIA Retirada de la prótesis inicia tto con Vancomicina EV OD: Artritis protésica de hombro por Propionibacterium acnes 2 semanas de tto antibiótico con Vancomicina en HAD , con Clindamicina y Rifampicina desde el alta HISTORIA TRAUMATOLÓGICA
- 5. HISTORIA TRAUMATOLÓGICA NUEVA PRÓTESIS EN ENERO No ha presentado signos inflamatorios ni de infección NO PROBLEMAS PARA SEGUNDO RECAMBIO PROTÉSICO
- 6. PATÓGENO OPORTUNISTA Propionibacterium acnes BACILO GRAM POSITIVO CONOCIDO PRINCIPALMENTE POR SU PAPEL EN EL ACNÉ Alexandra Perry & Peter Lambert (2011) Propionibacterium acnes: infection beyond the skin, Expert Review of Anti-infective Therapy, 9:12, 1149-1156, DOI: 10.1586/ eri.11.137 ANAEROBIO-AEROTOLERANTE
- 7. opportunistic pathogen Infecciones postoperatorias y relacionadas con el dispositivos médicos Huesos Articulaciones Boca Cerebro Expert Rev Anti Infect Ther. 2011 Dec;9(12):1149-56. doi: 10.1586/eri.11.137. Tambien se ha asociado con varias afecciones, como OSTEOMELITIS CRÓNICA RECURRENTE MULTIFOCAL CON ACNE Y PISTULOSIS (SAPHO) y sarcoidosis, aunque su función precisa como agente causal aún está por determinar. PATÓGENO OPORTUNISTA
- 8. Infections caused by Propionibacterium acnes. INFECCIONES POR Propionibacteium DERIVACIONES CEREBROESPINALES • (9%) • Cultivo anaeróbico con incubación prolongada • Formación de biofilms de P. Acnes en las derivaciones retiradas y destaca la importancia de la sonicación INFECCIONES DENTALES • Periodontitis lesiones endodónticas • Tipo II y III son los filotipos prevalentes ENDOCARDITIS • Prevalencia infraestimada • Válvulas cardíacas protésicas, anillos de anuloplastia , marcapasos • Endocarditis nativa (RARA)
- 9. Infections caused by Propionibacterium acnes. INFECCIONES POR Propionibacteium Infecciones neuroquirúrgicas y del SNC • Abscesos cerebrales que se presentan como infecciones postoperatorias tardías, • caso se presenta 10 años después de la cirugía • Meningitis y Empiema subdural y epidural. INFECCIONES OCULAR • Endoftalmitis posoperatoria tardía • También endoftalmitis endógena • Individuos inmunocomprome tidos y sanos • Queratitis (9%) • Algunas conjuntivitis DISQUITIS POSOPERATORIA, ESPONDILODISCITIS E INFECCIONES ESPINALES • Infección posoperatoria tardía de la columna se ha destacado con 13 casos reportados en la literatura entre 1955 y 2008 • refleja la abundancia de P. acnes en el cuero cabelludo y la espalda
- 10. Infections caused by Propionibacterium acnes Articulaciones protésicas e infecciones relacionadas con dispositivos ortopédicos La incidencia de infección articular prostética por P. acnes varía entre del 10 al 62%. En infecciones articulares protésicas, P. acnes puede causar infecciones crónicas tardías, colonización de prótesis y, en raras ocasiones, infecciones postoperatorias agudas Estudios utilizan prótesis reemplazadas adoptaron, un protocolo de transporte anaeróbico y sonicación suave para liberar las bacterias adherentes, lo que resultó en una mayor tasa de detección INFECCIONES POR Propionibacteium
- 11. condiciones predisponentes Cirugía previa Implantación de cuerpos extraños: Corazón protésico (válvulas) Derivaciones ventriculoperitoneales Lentes intraoculares Implantes ortopédicos Prótesis articulares. CONDICIONES PREDISPONENTES Manipulaciones repetidas de una articulación Alteración de la estructura anatómica de la articulación Mayor posibilidad de contaminación de la herida en el momento de la cirugía Aumento del riesgo en cirugías de larga duración Antecedentes de cirugía articular y el sexo masculino parecen ser factores de riesgo importantes Tropismo de Especies de Propionibacterium por glándulas sebáceas y bulbos capilares. La testosterona aumenta la población de Propionibacterium acnes.
- 12. P. acnes puede causar diferentes tipos de PJI Infecciones crónicas tardías Colonización de prótesis sueltas Excepcionalmente, infecciones postoperatorias agudas TIPOS DE INFECCIÓN 2007
- 13. SÍNTOMAS SINTOMAS Los principales síntomas de P. acnes PJI que se manifesta 2 años después de la cirugía: Dolor Disfunción conjunta. Síntomas de infección, como fiebre, inflamación, etc. La infección temprana se asoció con inflamación local de las articulaciones con mayor frecuencia que la tardía La infección se manifestó de media unos 210 días después de la cirugía ½ de todos los casos
- 14. Múltiples muestras de tejido intraoperatorio deben tomarse para confirmar el diagnóstico bacteriológico y debe ser cultivado por tiempos prolongados en medios enriquecidos. Tratamiento debe combinar la artroplastia de intercambio y prolongada terapia antibiótica intravenosa. La reintervención no es requerida en todos los casos TOMA DE MUESTRAS Y TRATAMIENTO
- 15. Las especies de Propionibacterium pueden formar biofilms en biomateriales ortopédicos, lo que dificulta la erradicación de una infección establecida sin retirada de la prótesis. 2/3 de los pacientes con articulaciones protésicas se sometieron eliminación de al estructura. BIOFILMS
- 16. 3 grupos separados de genes que codifican las enzimas implicadas en la biosíntesis de polisacáridos extracelulares y las proteínas de adhesión necesarias para la formación de biofilms In vitro, este modo de crecimiento ha demostrado que confiere una mayor resistencia a los agentes antimicrobianos La mayoría de los aislamientos de P. acnes de infecciones invasivas que involucran prótesis podían formar biofilm in vitro, mientras que los de piel sana eran pobres productores de biofilm en comparación. La producción de biofilm puede ser un determinante de la virulencia que permite las infecciones de dispositivos protésicos (mismas condiciones in vitro) Postula que la formación de biofilmen el folículo pilosebáceo puede actuar como "pegamento" que forma parte del tapón de acné. BIOFILMS Holmberg et al.
- 17. CULTIVO 13 días para la recuperación de P. acnes de pacientes con PJI. La incubación más allá de este período se asoció con una mayor recuperación de aislados no diagnósticos: (el 21,7%) Es importante destacar que un diagnóstico de P. acnes PJI se habría omitido en el 29,4% de los pacientes con una incubación de cultivo prolongada aplicada solo a medios de cultivo anaerobios. Estos resultados respaldan la necesidad de un período mínimo de incubación de cultivo de 13 días para ser aplicado tanto a condiciones aeróbicas como medios de cultivo anaeróbico para todos los especímenes periprotésicos.
- 18. CULTIVO El caldo de cultivo se incuba durante un período prolongado de 2 semanas y se subcultiva solo si se pone turbio P.acnes no siempre volvía el caldo turbio. (alta tasa de aislamiento.) Este protocolo de diagnóstico preciso de P.acnes permite tratamiento antibiótico específico eficaz dirigido por el patógeno
- 19. SONICACIÓN Cultivo microbiológico tienen sensibilidad y especificidad limitadas, lo que impide la diferenciación de PJI de otras fallas protésicas El uso de la sonicación para desprender las bacterias de la superficie protésica, ha mostrado mejoras prometedoras en la sensibilidad en comparación con la de los cultivos de tejidos tradicionales
- 20. TÉCNICNAS MOLECULARES PARA AUMENTAR LA SENSIBILIDAD ASOCIAR A TÉCNICAS MOLECULARES SECUENCIACIÓN 16S CULTIVOS NEGATIVOS CON ALTA SOSPECHA. PETICIÓN DIRECTA AL FACULTATIVO DE MICROBIOLOGÍA SIN DATOS DE SENSIBILIDAD
- 21. PROFILAXIS Profilaxis agresiva con antibióticos sistémicos y la preparación de la piel puede no tener éxito en la eliminación de Propionibacterium de la heridas quirúrgicas. Los organismos viven dentro de la dermis no se puede matar mediante la preparación quirúrgica habitual de la piela Los antibióticos sistémicos pueden no alcanzar las concentraciones bactericidas incluso con AB contra este grupo de microorganismos. Alentar al uso de riego abundante con solución salina con AB y manejo cuidadoso de las prótesis Tamaño del inóculo Formación de biofilms
- 22. TRATAMIENTO ANTIBIÓTICO En generales sensible a una amplia gama de antibióticos El Metronidazol es el único agente al que P. acnes es resistente y los aminoglucósidos generalmente tienen débil actividad La resistencia adquirida se ha producido debido al uso generalizado de antibióticos para tratar el acné. Los niveles más altos de resistencia se observan con la Clindamicina, la Eritromicina y la tetraciclina.
- 23. TRATAMIENTO ANTIBIÓTICO INFECCIÓN SISTÉMICA: BETALACTÁMICO ASOCIADO O NO A RIFAMPICINA. CLINDAMICINA EN ALÉRGICOS ALTERNATIVA: TEICO O VANCO Y RETIRADA DE MATERIAL EXTRAÑO
- 24. TAKE HOME MESSAGE.. PATÓGENO OPORTUNISTA (POCO VIRULENTO) ASOCIADO A CIRUGÍA Y DISPOSITIVOS MÉDICOS MÁS COMÚN EN HOMBRES DIFICIL PROFILAXIS INFECCIONES A LARGO PLAZO (BIOFILMS) INFRADIAGNOSTICADO CULTIVO (14 DÍAS)
- 25. BIBLIOGRAFIA 1. Characteristics and outcome of 16 periprosthetic shoulder joint infection. Y. Achermann F. Sahin HK Schwyzer C. Kolling J. Wu¨ st M. Vogt Infection 2013. 2. Postoperative Joint Infections Due to Propionibacterium Species: A Case-Control Study. Zeina A. Kanafani,1 Daniel J. Sexton,2 Brian C. Pien,2 Jay Varkey,2 Carl Basmania,2 and Keith S. Kaye3. CID 2009 3. Optimization of Periprosthetic Culture for Diagnosis of Propionibacterium acnes Prosthetic Joint Infection Susan M. Butler-Wu,1* Erica M. Burns,2† Paul S. Pottinger,3 Amalia S. Magaret,ennifer L. Rakeman,1‡ Frederick A. Matsen III,2 and Brad T. Cookson1,4. JOURNAL OF CLINICAL MICROBIOLOGY, July 2011, p. 2490–2495 4. Propionibacterium acnes: an underestimated etiology in the pathogenesis of osteoarthritis? Ofer Levy, MD, MCh (Orth), FRCSa,*, Shabnam Iyer, MBBS, MD, DTM&H, FRCPathb, Ehud Atoun, MD, MCh (Orth)a, Noel Peter, MRCSa, Nir Hous, MDa, Dave Cash, BSc (Hons)b, Fawaz Musa, MBChB, FRCPathc, Ali Narvani, FRCS (Orth & Trauma)a. J Shoulder Elbow Surg (2013) 22, 505-511 5. Propionibacterium can be isolated from deep cultures obtained at primary arthroplasty despite intravenous antimicrobial prophylaxis. Frederick A. Matsen III, MDa,*, Stacy M. Russb, Alexander Bertelsen, PACb, Susan Butler-Wu, PhDc, Paul S. Pottinger, MDd. J Shoulder Elbow Surg (2015) 24, 844-847. J Shoulder Elbow Surg (2015) 24, 844-847. Journal of Infection (2007) 55, 119e124
Notas del editor
- Propionibacterium acnes is a Gram-positive bacterium that forms part of the normal flora of the skin, oral cavity, large intestine, the conjunctiva and the external ear canal. Although primarily recognized for its role in acne, P. acnes is an opportunistic pathogen, causing a range of postoperative and device-related infections. These include infections of the bones and joints, mouth, eye and brain. Device-related infections include those of joint prostheses, shunts and prosthetic heart valves. P. acnes may play a role in other conditions, including inflammation of the prostate leading to cancer, SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome, sarcoidosis and sciatica. If an active role in these conditions is established there are major implications for diagnosis, treatment and protection. Genome sequencing of the organism has provided an insight into the pathogenic potential and virulence of P. acnes. Propionibacterium acnes, a common skin organism, is most notably recognized for its role in acne vulgaris. It also causes postoperative and device-related infections and has been associated with a number of other conditions such as sarcoidosis and synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO), although its precise role as a causative agent remains to be determined. Propionibacterium acnes produces a number of virulence factors and is well known for its inflammatory and immunomodulatory properties. Recent publication of the P. acnes genome should provide further insights into the pathogenic capabilities of the organism and potentially lead to the development of new therapies.
- Propionibacterium acnes is a Gram-positive bacterium that forms part of the normal flora of the skin, oral cavity, large intestine, the conjunctiva and the external ear canal. Although primarily recognized for its role in acne, P. acnes is an opportunistic pathogen, causing a range of postoperative and device-related infections. These include infections of the bones and joints, mouth, eye and brain. Device-related infections include those of joint prostheses, shunts and prosthetic heart valves. P. acnes may play a role in other conditions, including inflammation of the prostate leading to cancer, SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome, sarcoidosis and sciatica. If an active role in these conditions is established there are major implications for diagnosis, treatment and protection. Genome sequencing of the organism has provided an insight into the pathogenic potential and virulence of P. acnes. Propionibacterium acnes, a common skin organism, is most notably recognized for its role in acne vulgaris. It also causes postoperative and device-related infections and has been associated with a number of other conditions such as sarcoidosis and synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO), although its precise role as a causative agent remains to be determined. Propionibacterium acnes produces a number of virulence factors and is well known for its inflammatory and immunomodulatory properties. Recent publication of the P. acnes genome should provide further insights into the pathogenic capabilities of the organism and potentially lead to the development of new therapies.
- Cerebrospinal shunts P. acnes (9%), along with staphylococci, are among the most prevalent organisms associated with infections of cerebrospinal fluid shunts [12]. Anaerobic culture with extended incubation is therefore recommended if infection is suspected [13,14]. Furthermore, formation of P. acnes biofilms on removed shunts has been observed and highlights the importance of sonication to detach the microorganisms prior to culture [15]. Dental infections P. acnes has been isolated from root canals [16], cases of periodontitis [17,18] and endodontic lesions [19]. Using recA typing, Niazi et al. reported that P. acnes Type II and III are the prevalent phylotypes recovered from endodontic lesions [19].
- Cerebrospinal shunts P. acnes (9%), along with staphylococci, are among the most prevalent organisms associated with infections of cerebrospinal fluid shunts [12]. Anaerobic culture with extended incubation is therefore recommended if infection is suspected [13,14]. Furthermore, formation of P. acnes biofilms on removed shunts has been observed and highlights the importance of sonication to detach the microorganisms prior to culture [15]. Dental infections P. acnes has been isolated from root canals [16], cases of periodontitis [17,18] and endodontic lesions [19]. Using recA typing, Niazi et al. reported that P. acnes Type II and III are the prevalent phylotypes recovered from endodontic lesions [19].
- Prosthetic joints & orthopedic device-related infections In prosthetic joint infections P. acnes can cause late chronic infections, colonization of prostheses, and rarely, acute postoperative infections [42]. The reported incidence of P. acnes prosthetic joint infection varies between institutions from 10 [42] to 62% [43]. The latter study, using removed prostheses, adopted a protocol of anaerobic transport and mild sonication to release adherent bacteria which resulted in an increased detection rate. Sonication of removed prostheses [44] and extended culture periods up to 13 days [45] have been recommended to improve the diagnosis of infection.
- Major predisposing conditions are previous surgery and implantation of foreign bodies, such as prosthetic heart valves, ventriculoperitoneal shunts, intraocular lenses, orthopedic implants and joint prostheses.1,2,6,9,13e19 According to our observations, the major symptoms of P. acnes PJI that became manifest 2 years after index surgery, were pain and joint dysfunction. Symptoms of infection, like fever, inflammation and/or a sinus tract were observed in only half of these patients Objective: To describe the epidemiological, clinical and biological characteristics of Propionibacterium acnes PJI, their treatments and outcomes and compare 2 clinical pictures (according to the time PJI symptoms appeared after the index operation: 2 years, >2 years). A history of joint surgery prior to index surgery and male sex appear to be important risk factors for acquiring such infection. Our finding that male sex was an independent risk factor for Propionibacterium joint infection is consistent with the findings from a recent investigation of an outbreak of Propionibacterium postoperative shoulder infection [1]. One possible explanation of this sex preference relates to the tropism of Propionibacterium species for sebaceous glands and hair bulbs. Androgens promote the enlargement of sebaceous glands and hair growth in humans [10]. In addition, testosterone increases the population of Propionibacterium acnes on the skin of healthy postpubertal men [11]. As expected, a history of surgery on the affected joint prior to the index surgery was another independent predictor of Propionibacterium infection. Repeated manipulations of a joint increase the risk for postoperative infection because of the disturbance of the anatomical structure of the joint and the higher chance of wound contamination at the time of surgery
- Major predisposing conditions are previous surgery and implantation of foreign bodies, such as prosthetic heart valves, ventriculoperitoneal shunts, intraocular lenses, orthopedic implants and joint prostheses.1,2,6,9,13e19 Nearly all the patients (13/15) whose symptoms developed >2 years after the index surgery, had been admitted for presumed aseptic loosening, and can be classified as patients with positive intraoperative cultures according to Tsukuyama et al.25 These findings suggest infection in most of the patients whose PJI symptoms appeared: 2 years after the index operation, and colonization in the majority of those whose symptoms appeared >2 years after index surgery. Treatment combining exchange arthroplasty with prolonged intravenous antibiotics was successful for 92% of the patients. Conclusion: P. acnes can cause different types of PJI: late chronic infections, colonization of loosened prostheses and, exceptionally, acute postoperative infections.
- Major predisposing conditions are previous surgery and implantation of foreign bodies, such as prosthetic heart valves, ventriculoperitoneal shunts, intraocular lenses, orthopedic implants and joint prostheses.1,2,6,9,13e19 According to our observations, the major symptoms of P. acnes PJI that became manifest 2 years after index surgery, were pain and joint dysfunction. Symptoms of infection, like fever, inflammation and/or a sinus tract were observed in only half of these patients Objective: To describe the epidemiological, clinical and biological characteristics of Propionibacterium acnes PJI, their treatments and outcomes and compare 2 clinical pictures (according to the time PJI symptoms appeared after the index operation: 2 years, >2 years).
- Finally, we think that P. acnes can be responsible for different types of PJI: late chronic infections, colonization of loosened prostheses and, exceptionally, acute postoperative infections. Therefore, should P. acnes be isolated from preoperative joint aspirates of a patient clinically suspected of having PJI, it must be considered a potential pathogen. Multiple intraoperative tissue specimens should be taken to confirm the bacteriological diagnosis and should be cultured for prolonged times in enriched media. Treatment should combine exchange arthroplasty and prolonged intravenous antibiotic therapy. On the other hand, if P. acnes is found in intraoperative specimens from a patient undergoing surgery for presumed aseptic loosening who had been asymptomatic for many years, reintervention is not required, but an appropriate antibiotic regimen must be administered to avoid subsequent PJI
- specimen positive for Propionibacterium species is of uncertain clinical significance [14]. Therefore, in the diagnosis of Proprionibacterium species wound infection, deep cultures obtained either intraoperatively or via joint aspiration are needed. In this study, to avoid misclassification of case patients, stringent criteria for case selection were applied (deep monomicrobial operative cultures of Propionibacterium species and CDC criteria for surgical site infection diagnosis)
- Growth & identification of P. acnes P. acnes is able to form biofilms both in vitro and in vivo on a number of medical devices [15,83]. The genome sequence has revealed three separate clusters of genes that encode enzymes involved in the extracellular polysaccharide biosynthesis and adhesion proteins required for biofilm formation [81]. In vitro, this mode of growth has been shown to confer increased resistance to antimicrobial agents [83,84] and increased production of extracellular lipases [84]. Recently, Holmberg et al. found that the majority of P. acnes isolates from invasive infections involving prostheses were able to form biofilms in vitro, while those from healthy skin were poor biofilm producers in comparison. They went on to suggest that biofilm production may be a virulence determinant enabling infections of prosthetic devices [85]. It is important that in vitro biofilm assays used to explore the biofilm-forming ability of isolates are examined under growth conditions that accurately simulate growth conditions in vivo, for example, on the surface of an implant. Isolates of P. acnes from FBGT have also been shown to be biofilm producers and this may contribute to antimicrobial therapy failure in this condition [53]. Although not directly observed, it has been postulated that biofilm formation in the pilosebaceous follicle may act like ‘glue’ forming part of the acne plug [86]. P. acnes is capable of surviving for up to 8 months under anaerobic conditions suggesting that it could also persist in human tissues at low oxidation potentials [87]. P. acnes can survive inside alveolar macrophages [88] and has been observed inside cells from prostate tissues taken from patients with prostate cancer [58]. Infection of prostate epithelial cells stimulates upregulation of inflammatory cytokines and chemokines, with long term infection leading to cellular transformation [59]. Intracellular cell components of P. acnes have been observed in tissues from patients with renal sarcoidosis [89].
- determined that a 13-day culture incubation period is necessary for the recovery of P. acnes from patients with PJI. Incubation beyond this period was associated with increasing recovery of nondiagnostic isolates: 21.7% of P. acnes isolates believed to be clinically unimportant were recovered after 13 days of incubation. Importantly, a diagnosis of P. acnes PJI would have been missed in 29.4% of patients had extended culture incubation been applied only to anaerobic culture media. These results support the need for a minimum culture incubation period of 13 days to be applied to both aerobic and anaerobic culture media for all periprosthetic specimens. Optimal recovery of infecting organisms from PJI specimens will be an important component in generating a universal definition for PJI due to indolent agents of infection, such as P. acnes.
- Sch€afer et al23 reported that when culturing for P acnes, broth culture was incubated for a prolonged period of 2 weeks and it was subcultured only if it turned turbid. In our experience, P acnes did not always turn the broth turbid, and we identified P acnes after terminal subculture of apparently clear broth at the end of 5 days. This probably accounted for our high isolation rate. We believe that the protocol used in our study allows accurate P acnes diagnosis within several days after surgery, which enables early effective pathogen-directed specific antibiotic
- microbiologic culture (5–7), have limited sensitivity and specificity, which impedes the differentiation of PJI from other prosthetic failures use sonication to dislodge bacteria from the prosthetic surface, have shown promising improvements in sensitivity compared with that for traditional tissue cultures
- first to show that viable Propionibacterium can be recovered from primary arthroplasty wounds despite aggressive prophylaxis It is evident that organisms living within the dermis cannot be killed by the usual surgical skin surface preparation and that, even when targeted against this group of microorganisms, dual systemic antibiotics may not achieve bactericidal levels in the dermal structures This study has shown that Propionibacterium can be isolated fromdeep tissue cultures of patients undergoing primary shoulder arthroplasty despite aggressive antibiotic prophylaxis and skin preparation. Our observations indicate that aggressive prophylaxis with systemic antibiotics and skin preparation may not be successful in eliminating Propionibacterium from the surgical wounds of male patients undergoing shoulder arthroplasty. This realization may encourage the use of copious irrigation with antibiotic-containing saline solution and careful handling of the prostheses in an effort to reduce the size of the bacterial inoculum contacting the prosthesis and to reduce the risk of biofilm formation on the implants