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Determinants of methicillin-susceptible Staphylococcus aureusnative bone and joint infection treatment failure: a retrospective cohort study

  • Florent Valour1, 2, 9Email author,
  • Anissa Bouaziz1,
  • Judith Karsenty1,
  • Florence Ader1, 2,
  • Sébastien Lustig2, 3,
  • Frédéric Laurent2, 4,
  • Christian Chidiac1, 2 and
  • Tristan Ferry1, 2
BMC Infectious Diseases201414:443

DOI: 10.1186/1471-2334-14-443

Received: 5 April 2014

Accepted: 12 August 2014

Published: 16 August 2014

Abstract

Background

Although methicillin-susceptible Staphylococcus aureus (MSSA) native bone and joint infection (BJI) constitutes the more frequent clinical entity of BJI, prognostic studies mostly focused on methicillin-resistant S. aureus prosthetic joint infection. We aimed to assess the determinants of native MSSA BJI outcomes.

Methods

Retrospective cohort study (2001–2011) of patients admitted in a reference hospital centre for native MSSA BJI. Treatment failure determinants were assessed using Kaplan-Meier curves and binary logistic regression.

Results

Sixty-six patients (42 males [63.6%]; median age 61.2 years; interquartile range [IQR] 45.9–71.9) presented an acute (n = 38; 57.6%) or chronic (n = 28; 42.4%) native MSSA arthritis (n = 15; 22.7%), osteomyelitis (n = 19; 28.8%) or spondylodiscitis (n = 32; 48.5%), considered as “difficult-to-treat” in 61 cases (92.4%). All received a prolonged (27.1 weeks; IQR, 16.9–36.1) combined antimicrobial therapy, after surgical management in 37 cases (56.1%). Sixteen treatment failures (24.2%) were observed during a median follow-up period of 63.3 weeks (IQR, 44.7–103.1), including 13 persisting infections, 1 relapse after treatment disruption, and 2 super-infections. Independent determinants of treatment failure were the existence of a sinus tract (odds ratio [OR], 5.300; 95% confidence interval [CI], 1.166–24.103) and a prolonged delay to infectious disease specialist referral (OR, 1.134; 95% CI 1.013–1.271).

Conclusions

The important treatment failure rate pinpointed the difficulty of cure encountered in complicated native MSSA BJI. An early infectious disease specialist referral is essential, especially in debilitated patients or in presence of sinus tract.

Keywords

Staphylococcus aureus Bone and joint infection Treatment failure

Background

Bone and joint infections (BJIs) constitute difficult-to-treat clinical entities, known to be associated to significant morbidity and mortality rates. Most of the current literature on BJI concerns orthopaedic device infections and/or methicillin-resistant Staphylococcus aureus (MRSA). However, native infections represent the most frequent clinical form of BJI, accounting for approximately 70% of cases, and are mainly caused by methicillin-susceptible Staphylococcus aureus (MSSA) [1]. With a respective incidence of 4–10, 10 and 2.4 per 100,000 person-year, septic arthritis, osteomyelitis and vertebral osteomyelitis are associated with a mortality rate of 2-10%, and a risk of permanent loss of joint function of 40% [2, 3]. It has recently been shown that the setting of a systematic infectious disease specialist consultation in a septic orthopaedic surgery unit allows a better adjustment of empirical antimicrobial therapy [4]. However, risk factors for treatment failure have poorly been studied. We addressed this question in a retrospective cohort study.

Methods

All patients with native MSSA BJI were enrolled in a monocentric retrospective cohort study (2001–2011) in the reference center for the management of complex BJI of the Lyon University Hospitals, France. To be included, patients should present clinical evidences of infection and at least one reliable bacteriological sample positive for MSSA including percutaneous joint fluid aspiration, surgical sample, and/or blood culture, excluding patients with diabetic foot- and decubitus ulcer-related BJI because of the specific management of these infections. The time from initiation of symptoms of infection to diagnosis defined acute (infection lasting for ≤ 4 weeks) and chronic (infection lasting for > 4 weeks) infections [5]. The modified Charlson comorbidity index was calculated as previously described [6]. Immunosuppression was defined as: i) steroid therapy > 10 mg of prednisone per day or equivalent; ii) immunosuppressive drug during the two last months before BJI onset; or iii) chemotherapy. Treatment failure included i) persisting infection under appropriate antimicrobial therapy; and/or ii) relapse after antimicrobial therapy disruption.

Data were collected from medical records, nursing charts and biological software in an anonymous standardized case report form. Frequencies of the study variables were described as effectives (%) for dichotomous variables, and medians (interquartile range [IQR]) for continuous values. For the percentage calculation of each variable, the number of missing values was excluded from the denominator. Non-parametric statistical methods were used to compare the study groups (Khi2, Fisher exact test, Mann–Whitney U test), as appropriate. Kaplan-Meier curves were compared between groups using the log-rank test. Stepwise binary logistic regression was used to determine risk factors for treatment failure. After checking variables for interactions, variables with medical meaning and p values obtained in univariate analysis < 0.15 were included in the final multivariate model. A value of p < 0.05 was taken as significant. All analyses were performed using SPSS software version 17.0 (SPSS, Chicago, IL).

This study received the approval of the French South-East ethics committee with the reference number CAL2011-21. In accordance with the French legislation, written informed patient consent was not required for any part of the study.

Results

After exclusion of 4 diabetic foot- or decubitus ulcer-related infections and 7 patients with numerous missing values, 66 patients were enrolled in the analysis (42 males; 63.6%), with a median age of 61.2 years (IQR, 45.9–71.9). Demographic characteristics, comorbidities and BJI presentation are summarized in Table 1. Of note, 61 (92.4%) of included BJI were considered as difficult-to-treat, including chronic BJI (n = 28; 42.4%), local abscess (n = 33; 50.0%), sinus tract (n = 18; 27.3%), bacteraemia (n = 35; 53.0%) and/or associated infective endocarditis (n = 4; 6.1%). Importantly, in comparison with arthritis, osteomyelitis were more often chronic (n = 16 (84.2%) versus n = 2 (13.3%); p < 10−3), and sinus tract (n = 13 (68.4%) versus n = 2 (13.3%); p = 0.002) and abscesses (n = 10 (52.6%) versus n = 2 (13.3%); p = 0.030) were more frequent.
Table 1

Patient’s characteristics and risk factors for native methicillin-susceptible Staphylococcus aureus bone and joint infection treatment failure

Risk factor for treatment failure

Total (n = 66)

Treatment failure (n = 16)

Favourable outcome (n = 50)

p

Univariate analysis

       

OR (95%CI)

p

Demographic characteristics

      
 

Sex (male)

42 (63.6%)

10 (62.5%)

32 (64.0%)

0.913

0.938 (0.292-3.006)

0.938

 

Age (years)

61.2 (45.9-71.9)

61.2 (48.5-69.6)

60.4 (43.5-76.5)

0.828

1.119 (0.820-1.525)*

0.479

Comorbidity

      
 

Modified Charlson score

3.0 (0.0-5.0)

4.0 (2.5-5.0)

2.0 (0.0-4.0)

0.163

1.093 (0.907-1.318)

0.351

 

Modified Charlson score > 2

34 (51.5%)

12 (75.0%)

22 (44.0%)

0.044

3.818 (1.081-13.486)

0.037

 

Obesity (BMI > 30 kg/m2)

13 (20.0%)

3 (20.0%)

10 (20.0%)

1.000

1.000 (0.236-4.231)

1.000

 

Denutrition (BMI < 18 kg/m2)

3 (4.6%)

1 (6.7%)

2 (4.0%)

1.000

1.714 (0.145-20.332)

0.669

 

Diabetes

11 (16.7%)

6 (37.5%)

5 (10.0%)

0.018

5.400 (1.372-21.260)

0.016

 

Immunodepression

8 (12.1%)

3 (18.8%)

5 (10.0%)

0.390

2.077 (0.437-9.871)

0.358

 

Nephropathy

10 (15.2%)

3 (18.8%)

7 (14.0%)

0.695

1.418 (0.320-6.277)

0.646

 

Hepatopathy

2 (3.0%)

2 (12.5%)

0 (0%)

0.056

NC

NC

 

Chronic pulmonary disease

12 (18.2%)

4 (25.0%)

8 (16.0%)

0.465

1.750 (0.449-6.825)

0.420

 

Chronic heart failure

5 (7.6%)

0 (0%)

5 (10.0%)

0.325

NC

NC

 

Chronic inflammatory disease

7 (10.6%)

2 (12.5%)

5 (10.0%)

1.000

1.286 (0.224-7.370)

0.778

 

Neoplasm, hemopathy

7 (10.6%)

1 (6.3%)

6 (12.0%)

0.674

0.489 (0.054-4.397)

0.523

 

Dementia

1 (1.5%)

1 (6.3%)

0 (0%)

0.242

NC

NC

BJI type

      
 

Arthritis

15 (22.7%)

3 (18.8%)

12 (24.0%)

0.747

0.731 (0.178-3.003)

0.731

 

Osteomyelitis

19 (28.8%)

8 (50.0%)

11 (22.0%)

0.054

3.545 (1.082-11.615)

0.037

 

Vertebral osteomyelitis

32 (48.5%)

5 (31.3%)

27 (54.0%)

0.195

0.387 (0.117-1.279)

0.120

BJI mechanism

      
 

Haematogenous

40 (60.6%)

8 (50.0%)

32 (64.0%)

0.480

0.563 (0.180-1.754)

0.321

 

Inoculation

22 (33.3%)

7 (43.8%)

15 (30.0%)

0.475

1.815 (0.570-5.779)

0.313

 

Contiguity

4 (6.1%)

1 (6.3%)

3 (6.0%)

1.000

1.044 (0.101-10.806)

0.971

BJI diagnosis

      
 

Fever

43 (65.2%)

10 (62.5%)

33 (66.0%)

1.000

0.859 (0.267-2.764)

0.798

 

Fistula

18 (27.3%)

7 (43.8%)

11 (22.0%)

0.112

2.758 (0.836-9.092)

0.096

 

Abscess

33 (50.0%)

7 (43.8%)

26 (52.0%)

0.775

0.718 (0.231-2.229)

0.566

 

Chronic BJI (evolution > 4 weeks)

28 (42.4%)

8 (50.0%)

20 (40.0%)

0.680

1.500 (0.484-4.651)

0.483

 

Delay from symptoms to diagnosis (weeks)

2.1 (0.0-10.3)

2.6 (0.0-34.4)

2.1 (0.5-9.8)

0.905

1.026 (0.996-1.057)

0.095

 

Polymicrobial BJI

10 (15.2%)

3 (18.8%)

7 (14.0%)

0.695

1.418 (0.320-6.277)

0.646

 

Infective endocarditis

4 (6.1%)

0 (0%)

4 (8.0%)

0.565

NC

NC

 

Biological inflammatory syndrome

58 (87.9%)

16 (100%)

42 (84.0%)

0.183

NC

NC

  

Maximal CRP value (mg/L)

152.7 (52.0-317.8)

145.0 (75.3-317.3)

154.7 (52.0-325.9)

0.994

1.000 (0.996-1.004)

0.931

  

Maximal WBC count value (/mm3)

10,200 (7,720-14,920)

11,000 (10,200-16,280)

9,710 (7,350-14,770)

0.100

1.058 (0.961-1.164)

0.251

  

Maximal neutrophil count value (/mm3)

7,600 (5,200-11,970)

9,300 (6,740-13,470)

7,380 (5,200-11,400)

0.292

1.056 (0.957-1.165)

0.277

 

Chronic sepsis on pathological examination

9/21 (47.4%)

2/3 (66.7%)

7/16 (43.8%)

0.582

2.571 (0.192-34.473)

0.476

Surgical treatment

37 (56.1%)

11 (68.8%)

26 (52.0%)

0.377

2.031 (0.615-6.701)

0.245

 

Delay from symptoms to surgery (days)

3 (0–12.5)

0 (0–9)

4 (0–12)

0.402

0.999 (0.994-1.004)

0.632

Antibiotic use

      
 

Delay from diagnosis to specialist referral (days)

4.9 (0.0-23.1)

6.3 (0.7-91.0)

4.9 (0.0-18.5)

0.445

1.102 (1.003-1.211)

0.043

 

i.v.treatment

59 (89.4%)

13 (81.3%)

46 (92.0%)

0.347

0.377 (0.075-1.901)

0.237

  

i.v.treatment duration (weeks)

7.1 (4.9-11.7)

9.1 (5.3-16.4)

7.0 (4.6-9.4)

0.297

1.037 (0.986-1.091)

0.156

 

Bitherapy

66 (100%)

16 (100%)

50 (100%)

1.000

NC

NC

  

Bitherapy duration (weeks)

25.6 (15.0-32.1)

27.0 (17.4-38.5)

25.1 (15.1-31.1)

0.533

1.016 (0.983-1.050)

0.345

  

Initial anti-staphylococcal bitherapy

53 (81.5%)

12 (75.0%)

41 (83.7%)

0.719

0.585 (0.150-2.285)

0.441

  

Initial anti-MSSA bitherapy

40 (61.5%)

8 (50.0%)

32 (65.3%)

0.480

0.531 (0.169-1.666)

0.278

Biological follow-up

      
 

1 month CRP level

13.0 (3.6-36.0)

13.3 (7.4-70.4)

11.0 (3.2-31.9)

0.296

1.006 (0.994-1.018)

0.315

 

Decrease in CRP level at 1 month < 50%

9 (13.8%)

4 (26.7%)

5 (10.0%)

0.204

3.273 (0.752-14.245)

0.114

 

1 month CRP level < 10 mg/L

29 (44.6%)

5 (33.3%)

24 (48.0%)

0.377

0.542 (0.162-1.814)

0.320

Results are presented as n (%) for dichotomic variables compared using Chi-square or Fisher exact tests, and median (interquartile range) for continuous variables, compared using Mann–Whitney U-test. Risk factors for treatment failure were assessed using logistic binary regression.

*For a 10-year increase in age.

BJI, Bone and joint infection; CI, Confidence interval; BMI, Body mass index; CRP, C-reactive protein; i.v., Intravenous; MSSA, Methicillin-susceptible Staphylococcus aureus; NC, Not calculable; OR, Odds ratio; WBC, White blood cells.

A surgical management was performed in 37 cases (56.1%). All patients received antimicrobial therapy for 27.1 weeks (IQR, 16.9–36.1), initially administrated intravenously in 59 patients (89.4%) for 7.1 weeks (IQR, 4.9–11.7). All patients received a combined antistaphylococcal therapy during almost all treatment duration (25.6 weeks; IQR, 15.0-32.1). The antimicrobial were chosen according to recommendations and microbiological susceptibility testing in all cases, with respect of contraindications (i.e., drug interactions, previous adverse events …). The main used molecules, doses and duration are presented in Table 2. Of note, 25 patients (37.9%) received glycopeptides, given as initial empirical therapy (n = 4; for a total duration ≤ 14 days), a previous allergic reaction to other antistaphylococcal antibiotics (n = 12), a polymicrobial infection (n = 5), or difficult venous access (n = 4, then using subcutaneous teicoplanin).
Table 2

Main antimicrobial used in the 66 included patients with native methicillin-susceptible Staphylococcus aureus native bone and joint infection

 

All patients (n = 66)

Treatment failure (n = 16)

Favorable outcome (n = 50)

p

i.v anti-staphylococcal penicillin

49 (74.2%)

11 (68.8%)

38 (76.0%)

0.743

 

Dose (mg/kg/day)

144.6 (133.3-169.0)

141.2 (133.3-150.0)

144.9 (133.6-172.7)

0.606

 

Duration (weeks)

6.0 (3.0-8.0)

6.7 (4.1-12.2)

5.2 (2.7-7.4)

0.250

Glycopeptides

25 (37.9%)

7 (43.8%)

18 (36.0%)

0.768

 

Vancomycine,

10 (15.2%)

1 (6.3%)

9 (18.0%)

0.430

 

Dose (mg/kg/day)

26.0 (20.3-30.5)

25

27.0 (19.2-31.3)

NC

 

Teicoplanin

22 (33.3%)

6 (37.5%)

16 (32.0%)

0.764

 

Dose (mg/kg/day)

5.7 (4.1-7.0)

7.2 (5.4-8.4)

5.2 (3.9-6.5)

0.197

 

Duration

3.4 (2.6-7.6)

3.4 (1.9-16.1)

3.9 (2.8-6.7)

0.832

Aminoglycosides

38 (57.6%)

9 (56.3%)

29 (58.0%)

1.000

Rifampin

36 (54.5%)

9 (56.3%)

27 (54.0%)

1.000

 

Dose (mg/kg/day)

18.8 (14.6-21.2)

18.0 (14.6-21.4)

18.8 (15.2-20.8)

0.841

 

Duration (weeks)

20.3 (2.7-34.6)

27.5 (11.8-53.1)

16.0 (2.7-25.3)

0.334

Fluoroquinolones

62 (93.9%)

15 (93.8%)

47 (94.0%)

1.000

 

Ofloxacin dose (mg/kg/day)

6.7 (5.8-7.5)

7.1 (6.3-7.5)

6.35 (5.7-7.3)

0.240

 

Duration (weeks)

14.6 (8.0-27.6)

17.0 (10.9-31.9)

14.6 (7.6-24.4)

0.397

Macrolid group

46 (69.7%)

10 (62.5%)

36 (72.0%)

0.538

 

Clindamycin

17 (25.8%)

6 (37.5%)

11 (22.0%)

0.324

 

Pristinamycin

33 (50.0%)

5 (31.3%)

28 (56.0%)

0.150

Linezolid

6 (9.1%)

1 (6.3%)

5 (10.0%)

1.000

Fucidic acid

4 (6.1%)

1 (6.3%)

3 (6.0%)

1.000

Fosfomycin

13 (19.7%)

4 (25.0%)

9 (18.0%)

0.719

Cotrimoxazole

2 (3.0%)

1 (6.3%)

1 (2.0%)

0.429

i.v: intravenous.

Difference between the two groups were assessed using Chi-square test or Fisher exact test for dichotomic variables, and Mann–Whitney U-test for continuous variables.

Treatment failure was observed in 16 cases (24.2%) during a median follow-up period of 63.3 weeks (IQR, 44.7–103.1): i) 13 patients (19.7%) with persistent infection including 9 patients requiring new surgery performed in a delay of 11.6 weeks (IQR, 5.3–25.6) after antimicrobial treatment initiation; ii) one relapse occurring 13.7 weeks after treatment disruption; and iii) 2 super-infections (one with Staphylococcus epidermidis, and one with Enterococcus faecalis and Streptococcus intermedius). Final evolution was favourable in 12 of the 16 patients with initial treatment failure. Three patients had to be amputated. Five patients (7.6%) died during follow-up, without sepsis-related death. Of note, one fatal pulmonary embolism linked with prolonged bed rest occurred. At the end of follow-up, 24 patients (38.1%) presented functional sequels, consisting in chronic pain and/or loss of function.

Patients presenting a treatment failure did not differ from those with favourable outcome regarding their baseline characteristics, with the exception of a higher prevalence of diabetes (37.5% versus 10%; p = 0.018) and a higher number of patients presenting a modified Charlson comorbidity index > 2 (75.0% versus 44.0%; p = 0.044). There was no difference between the two groups regarding the use of the main administered antimicrobials (Table 2). The delay from diagnosis to infectious disease specialist advice (i.e. first phone contact, consultation or hospitalization) tended to have been higher for patients with treatment failure (6.3 days; IQR, 0.7–91.0; p = 0.445), and especially for those with persistent infection (7.7 days; IQR, 0.4–161.0; p = 0.217) than for patients with favourable outcome. In univariate analysis, diabetes (Odd ratio [OR], 5.4; 95% confidence interval [CI], 1.372–21.260; p = 0.016), osteomyelitis (OR, 3.545; 95% CI, 1.082–11.615; p = 0.037), and a prolonged delay for infectious disease specialist referral (OR, 1.102; 95% CI, 1.003–1.211; p = 0.043) were associated with treatment failure (Table 1, Figure 1). Non-interacting and clinically relevant factors included in the multivariate logistic regression model were a modified Charlson comorbidity index > 2 (OR, 3.322; 95% CI, 0.753–14.661; p = 0.113), the existence of a sinus tract (OR, 5.300; 95% CI, 1.166–24.103; p = 0.031), a delayed referral to infectious disease specialist (OR, 1.134; 95% CI, 1.013–1.271; p = 0.029), and a decreased in CRP level at 1 month < 75% (OR, 3.183; 95% CI, 0.727–13.936; p = 0.124).
https://static-content.springer.com/image/art%3A10.1186%2F1471-2334-14-443/MediaObjects/12879_2014_Article_3746_Fig1_HTML.jpg
Figure 1

Kaplan-Meier curves for the cumulative risk of treatment failure. Kaplan-Meier curves for the cumulative risk of treatment failure are presented according to the modified Charlson comorbidity index (panel A), the presence of diabetes (panel B) or sinus tract (panel C), and the 1-month CRP level (panel D). Groups were compared using the log-rank test.

Discussion

In this retrospective cohort study including patients with native MSSA BJI, we pinpointed an important rate of unfavourable outcome, including a treatment failure rate reaching one quarter of patients and high proportion of functional sequels. These results should be interpreted in light of the high prevalence of difficult-to-treat infections enrolled in the study, due to the particular recruitment of our institution, a reference centre for the management of complex BJI. Moreover, the implication of S. aureus is known to be associated with a poorer outcome of native and device-associated septic arthritis [79]. However, these findings are consistent with the few available data in the literature [2, 10]. Most of studies focusing on native staphylococcal BJI outcome were large epidemiologic investigations, based on national health surveillance programs, and consequently not design to assess precise outcome but only mortality. In a previous study, Wieland et al. disclosed a treatment failure rate of 12.2% among 41 native MSSA BJI [11]. Although these authors provided no detailed information about the type of patient recruitment, the short treatment court duration (43 days) and the low amount of patient requiring nursing home or rehabilitation facility (11%) allow supposing that common forms of BJI were more represented. In our particular patient population requiring long-term antimicrobial therapy, independent risk factors for treatment were the presence of a sinus tract and a delayed referral to infectious disease specialist. Fistula has already been associated with poor outcome in prosthetic-joint infection and vertebral osteomyelitis [12, 13]. Our findings confirmed that this clinical evidence for chronic infection is associated with treatment failure of native BJI. Diabetes was associated with a higher risk of treatment failure in univariate analysis but was excluded from the final model because the parameter was included in the Charlson comorbidity score calculation. However, it is a well-known risk factor for treatment failure [14]. Interestingly, we observed a trend in a higher treatment failure rate in bone infections (50.0%) compared to arthritis (18.8%). This difference probably lies in the higher rate of chronic infections, sinus tracts and abscesses among the osteomyelitis cases. Indeed, in the study by Wieland and colleagues, these two BJI types harboured the same outcome [11].

The impact of a referral to infectious disease specialist has been evaluated in several studies, which showed a benefit in terms of early adaptation of the initial empirical therapy after bacteriological results, and regarding dosages and duration of antimicrobials [4, 15]. However, these series failed to highlight an improvement of BJI outcome. Nevertheless, Bauer and colleagues showed a decrease from 25 to 18% of treatment failure rate after the instauration of a weekly multidisciplinary staff meeting in their institution, even if this difference was not significant [15].

Some studies had found other determinants of poor outcome in native BJI, including advanced age, a raised white cell count at presentation, the presence of an abscess, a delayed initiation of antimicrobial treatment, a pre-existing joint disease which may delay diagnosis [9, 13, 1618]. We failed to found any association between outcome and the nature of antimicrobial therapy, and especially with the use of glycopeptides used as empirical therapy, for polymicrobial infection, or in patients with beta-lactam allergy. Indeed, vancomycin therapy has been associated with a poor outcome in MSSA bacteraemia, due to its slow bactericidal activity [19, 20]. One study including a majority of MSSA native osteomyelitis also suggested that vancomycin-treated infections were nearly three-times more likely to recur [21]. Contrary to prosthetic-joint infections, the use of rifampin did not appear as a protective factor in our study, possibly because of the less important implication of biofilm in absence of orthopaedic device. Finally, if the optimal treatment duration of BJI is unknown, a longer antimicrobial therapy did not appear as a protective factor. Prolonged antimicrobial therapy observed in our study is partly explained by the complicated nature of the included BJI. Another explanation lies in the retrospective nature of the study, which included patients in a 10-year period. Even in the absence of controlled randomized trial, the absence of evidence regarding the benefit of prolonged treatment lead to progressively decrease treatment duration in our population, without increasing failure rate over years (data not shown). Prospective controlled studies are needed to confirm the feasibility of shorter treatments. However, some studies had suggested that reducing treatment duration was associated with an increased risk of treatment failure, notably in vertebral osteomyelitis [22].

Conclusions

MSSA native BJI are associated with a high rate of treatment failure and sequel, despite the use of prolonged antimicrobial therapy. A multidisciplinary approach is required, with an early referral to infectious disease specialist, especially in debilitated patients or in presence of a sinus tract.

Abbreviations

BJI: 

Bone and joint infection

CI: 

Confidence interval

IQR: 

Interquartile range

MRSA: 

Methicillin-resistant Staphylococcus aureus

MSSA: 

Methicillin-susceptible Staphylococcus aureus

OR: 

Odds ratio.

Declarations

Acknowledgements

Lyon Bone and Joint Infection Study Group: Physicians – Florence Ader, François Biron, André Boibieux, Anissa Bouaziz, Evelyne Braun, Christian Chidiac, Fatiha Daoud, Tristan Ferry, Judith Karsenty, Johanna Lippman, Patrick Miailhes, Thomas Perpoint, Dominique Peyramond, Marie-Paule Vallat, Florent Valour; Surgeons – Cédric Barrey, Pierre Breton, Fabien Boucher, Romain Desmarchelier, Michel-Henry Fessy, Olivier Guyen, Christophe Lienhart, Sébastien Lustig, Alain-Ali Mojallal, Philippe Neyret, Franck Trouillet, Gualter Vaz; Microbiologists – Frédéric Laurent, Jean-Philippe Rasigade, François Vandenesch; Nuclear Medicine – Emmanuel Deshayes, Francesco Giammarile, Marc Janier, Isabelle Morelec; PK/PD specialists – Marie-Claude Gagnieu, Sylvain Goutelle, Michel Tod; Clinical Research Assistant – Marion Martinez

Authors’ Affiliations

(1)
Service des maladies infectieuses et tropicales, Hospices Civils de Lyon, Groupement Hospitalier Nord
(2)
Université Claude Bernard Lyon 1, INSERM U1111, International Centre for Research in Infectious diseases
(3)
Chirurgie orthopédique, Hospices Civils de Lyon, Groupement Hospitalier Nord
(4)
Laboratoire de bactériologie, Centre National de Référence des Staphylocoques, Hospices Civils de Lyon
(5)
the Lyon BJI study group

References

  1. Grammatico-Guillon L, Baron S, Gettner S, Lecuyer AI, Gaborit C, Rosset P, Rusch E, Bernard L: Bone and joint infections in hospitalized patients in France, 2008: clinical and economic outcomes. J Hosp Infect. 2012, 82: 40-48.View ArticlePubMedGoogle Scholar
  2. Garcia-Arias M, Balsa A, Mola EM: Septic arthritis. Best Pract Res Clin Rheumatol. 2011, 25: 407-421.View ArticlePubMedGoogle Scholar
  3. Mathews CJ, Weston VC, Jones A, Field M, Coakley G: Bacterial septic arthritis in adults. Lancet. 2010, 375: 846-855.View ArticlePubMedGoogle Scholar
  4. Uckay I, Vernaz-Hegi N, Harbarth S, Stern R, Legout L, Vauthey L, Ferry T, Lübbeke A, Assal M, Lew D, Hoffmeyer P, Bernard L: Activity and impact on antibiotic use and costs of a dedicated infectious diseases consultant on a septic orthopaedic unit. J Infect. 2009, 58: 205-212.View ArticlePubMedGoogle Scholar
  5. Tsukayama DT, Estrada R, Gustilo RB: Infection after total hip arthroplasty. A study of the treatment of one hundred and six infections. J Bone Joint Surg Am. 1996, 78: 512-523.PubMedGoogle Scholar
  6. Charlson M, Szatrowski TP, Peterson J, Gold J: Validation of a combined comorbidity index. J Clin Epidemiol. 1994, 47: 1245-1251.View ArticlePubMedGoogle Scholar
  7. Azzam KA, Seeley M, Ghanem E, Austin MS, Purtill JJ, Parvizi J: Irrigation and debridement in the management of prosthetic joint infection: traditional indications revisited. J Arthroplasty. 2010, 25: 1022-1027.View ArticlePubMedGoogle Scholar
  8. Byren I, Bejon P, Atkins BL, Angus B, Masters S, McLardy-Smith P, Gundle R, Berendt A: One hundred and twelve infected arthroplasties treated with 'DAIR' (debridement, antibiotics and implant retention): antibiotic duration and outcome. J Antimicrob Chemother. 2009, 63: 1264-1271.View ArticlePubMedPubMed CentralGoogle Scholar
  9. Dubost JJ, Fis I, Denis P, Lopitaux R, Soubrier M, Ristori JM, Bussiere JL, Sirot J, Sauvezie B: Polyarticular septic arthritis. Medicine (Baltimore). 1993, 72: 296-310.View ArticleGoogle Scholar
  10. Weston VC, Jones AC, Bradbury N, Fawthrop F, Doherty M: Clinical features and outcome of septic arthritis in a single UK Health District 1982–1991. Ann Rheum Dis. 1999, 58: 214-219.View ArticlePubMedPubMed CentralGoogle Scholar
  11. Wieland BW, Marcantoni JR, Bommarito KM, Warren DK, Marschall J: A retrospective comparison of cetriaxone versus oxacillin for osteoarticular infections due to methicillin-susceptible Staphylococcus aureus. Clin infect Dis. 2012, 54: 585-590.View ArticlePubMedGoogle Scholar
  12. Marculescu CE, Berbari EF, Hanssen AD, Steckelberg JM, Harmsen SW, Mandrekar JN, Osmon DR: Outcome of prosthetic joint infections treated with debridement and retention of components. Clin Infect Dis. 2006, 42: 471-478.View ArticlePubMedGoogle Scholar
  13. McHenry MC, Easley KA, Locker GA: Vertebral osteomyelitis: long-term outcome for 253 patients from 7 Cleveland-area hospitals. Clin Infect Dis. 2002, 34: 1342-1350.View ArticlePubMedGoogle Scholar
  14. Gomez J, Rodriguez M, Banos V, Martinez L, Claver MA, Ruiz J, Simarro E, Canovas JA, Medina M, Clavel M: Orthopedic implant infection: prognostic factors and influence of long-term antibiotic treatment on evolution. Prospective study, 1992–1999. Enferm Infecc Microbiol Clin. 2003, 21: 232-236.View ArticlePubMedGoogle Scholar
  15. Bauer S, Bouldouyre MA, Oufella A, Palmari P, Bakir R, Fabreguettes A, Gros H: Impact of a multidisciplinary staff meeting on the quality of antibiotherapy prescription for bone and joint infections in orthopedic surgery. Med Mal Infect. 2012, 42: 603-607.View ArticlePubMedGoogle Scholar
  16. D'Agostino C, Scorzolini L, Massetti AP, Carnevalini M, d'Ettorre G, Venditti M, Vullo V, Orsi GB: A seven-year prospective study on spondylodiscitis: epidemiological and microbiological features. Infection. 2010, 38: 102-107.View ArticlePubMedGoogle Scholar
  17. Gupta MN, Sturrock RD, Field M: A prospective 2-year study of 75 patients with adult-onset septic arthritis. Rheumatology (Oxford). 2001, 40: 24-30.View ArticleGoogle Scholar
  18. Tarkowski A: Infection and musculoskeletal conditions: Infectious arthritis. Best Pract Res Clin Rheumatol. 2006, 20: 1029-1044.View ArticlePubMedGoogle Scholar
  19. Chang FY, Peacock JE, Musher DM, Triplett P, MacDonald BB, Mylotte JM, O’Donnell A, Wagener MM, Yu VL: Staphylococcus aureus bacteremia: recurrence and the impact of antibiotic treatment in a prospective multicenter study. Medicine (Baltimore). 2003, 82: 333-339.View ArticleGoogle Scholar
  20. Kim SH, Kim KH, Kim HB, Kim NJ, Kim EC, Oh MD, Choe KW: Outcome of vancomycin treatment in patients with methicillin-susceptible Staphylococcus aureus bacteremia. Antimicrob Agents Chemother. 2008, 52: 192-197.View ArticlePubMedGoogle Scholar
  21. Tice AD, Hoaglund PA, Shoultz DA: Risk factors and treatment outcomes in osteomyelitis. J Antimicrob Chemother. 2003, 51: 1261-1268.View ArticlePubMedGoogle Scholar
  22. Priest DH, Peacock JE: Hematogenous vertebral osteomyelitis due to Staphylococcus aureus in the adult: clinical features and therapeutic outcomes. South Med J. 2005, 98: 854-862.View ArticlePubMedGoogle Scholar
  23. Pre-publication history

    1. The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/14/443/prepub

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© Valour et al.; licensee BioMed Central Ltd. 2014

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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