Paper of the week: Orthopedic Implant-Associated Infection by Multidrug Resistant Enterobacteriaceae. Pfang BG, García-Cañete J, García-Lasheras J, Blanco A, Auñón Á, Parron-Cambero R, Macías-Valcayo A, Esteban J. J Clin Med. 2019 Feb 8;8(2). pii: E220. doi: 10.3390/jcm8020220.
Summary and Editorial by Sreeram Penna
This is a retrospective observational study from a single institution. Researchers reviewed all cases of orthopaedic implant-associated multidrug-resistant Enterobacteriaceae (MDREB). The overall incidence of MDREB was 6.4% (31/482). Six patients were excluded, and twenty-five patients are included in the study. Patients included ten prosthetic joints, seven osteosyntheses, six combination of prosthetic joint and osteosynthesis, and two spacers. MDREB is defined as any enterobacteria resistant to three or more antibacterial classes. Bacteria in this cohort was 12 extended spectrum beta-lactamase producing Escherichia coli, 3 OXA-48-carbapenamase producing Klebsiella pneumoniae, nine extended-spectrum beta-lactamase producing Proteus mirabilis and ten cases were polymicrobial infections. Overall 16 patients (64%) underwent implant removal. This included 7 cases of resection arthroplasty and 3 cases of Amputation. All patients with implant removal achieved 100% infection clearance. Only 33% of patients with retained implants had infection clearance. Four patients died within one year of diagnosis.
Literature review shows an increase in multidrug-resistant Gram-negative bacterial joint infections. These multidrug-resistant Gram-negative bacterial infections are often difficult to control and require special antibiotics combinations to treat and also to prevent further development of antibiotic resistance. Surgical procedures require implant removal for infection clearance. This study provides further insights into MDREB orthopaedic implant infections and clearly shows how dangerous these are.
 Murillo O, Grau I, Lora-Tamayo J, Gomez-Junyent J, Ribera A, Tubau F, et al. The changing epidemiology of bacteraemic osteoarticular infections in the early 21st century. Clin Microbiol Infect 2015;21:254.e1-8. doi:10.1016/j.cmi.2014.09.007.
 Hawkey PM, Warren RE, Livermore DM, McNulty CAM, Enoch DA, Otter JA, et al. Treatment of infections caused by multidrug-resistant Gram-negative bacteria: report of the British Society for Antimicrobial Chemotherapy/Healthcare Infection Society/British Infection Association Joint Working Party. J Antimicrob Chemother 2018;73:iii2–78. doi:10.1093/jac/dky027.
 Papadopoulos A, Ribera A, Mavrogenis AF, Rodriguez-Pardo D, Bonnet E, Salles MJ, et al. Multidrug-resistant and extensively drug-resistant Gram-negative prosthetic joint infections: Role of surgery and impact of colistin administration. Int J Antimicrob Agents 2018. doi:10.1016/j.ijantimicag.2018.10.018.