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PROSTHETIC KNEE ARTHRITIS DUE TO GRANULICATELLA ADIACENS
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AFTER DENTAL CARES
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F. Mougari1,2,*, H. Jacquier1,3, B. Berçot1,2, D. Hannouche4,5, R. Nizard4,5, E. Cambau1,2, F.
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Zadegan4,5
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F-75475 Paris ; 2EA 3964, Université Paris Diderot, 3INSERM, UMR-S 722 and Université
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Paris Diderot, Sorbonne Paris Cité, Faculté de Médecine, Paris; 4Service de Chirurgie
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Orthopédique et traumatologique, Groupe Hospitalier Lariboisière-Fernand Widal, APHP, F-
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75475 Paris ; 5INSERM U606, Centre Viggo Petersen and Université Paris-Diderot.
Service de Bactériologie-Virologie, Groupe Hospitalier Lariboisière-Fernand Widal, APHP,
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* Correspondence: Mailing address: Faiza Mougari, Service de Bactériologie-Virologie,
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Groupe Hospitalier Lariboisière-Fernand Widal, AP-HP, Paris, France. Phone: +33-1-49-95-
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65-44. Fax: +33-1-49-95-85-37. E-mail:
[email protected]
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Abstract
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We report prosthetic knee arthritis in a 55-year-old diabetic man due to Granulicatella
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adiacens, a microorganism present in the oral flora, usually described in endocarditis but
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rarely in prosthesis joint infection. This patient had a dental extraction without antibiotic
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prophylaxis one month before, whereas an aseptic loosening of the prosthesis was previously
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diagnosed. If antimicrobial prophylaxis against infective endocarditis for dental procedure is
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well established, such an approach is still controversial for joint prosthesis and must be
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discussed in some conditions.
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Introduction:
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Joint replacement prosthesis became a common procedure in orthopedic surgery. The most
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feared complication is infection. Infection rate due to intraoperative contamination has
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decreased thanks to antibiotic prophylaxis and aseptic conditions. However, the absolute
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number of patients with device-associated infection increases, due to the growing number of
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arthroplasties performed and longevity of patients, associated to the risk of secondary
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contamination, particularly from haematogenous dissemination (Zimmerli & Ochsner, 2003).
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Dental infections and oral care are one of the main causes of arthroplasty infection, after skin
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and urinary tract portals of entry (Maderazo et al., 1988). However there is no formal
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evidence confirming the relationship between oral or dental care and arthroplasty infection
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(Berbari et al., 2010; Legout et al., 2012; Skaar et al., 2011).
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Here we describe a case report of prosthetic knee arthritis occurring after dental cares and due
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to Granulicatella adiacens, a nutritionally variant of Streptococcus belonging to the oral flora.
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Case report:
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A 55-year-old diabetic man was admitted in our hospital in July 2009 for a right knee
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pain. He had a right knee traumatism in 1988 caused by a road traffic accident, that required
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tibial osteotomy. Total right knee prosthesis was implanted in 1999 for malunion and the
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patient healed without any septic complication. Since 2008, the patient had reported
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progressive knee pain and decrease in joint mobility. In March 2009, an aseptic loosening of
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the prosthesis was diagnosed on radiological, microbiological and clinical data: the artho-CT
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(computed tomography) scan showed osteolysis and loosening of the total knee prosthesis,
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knee puncture showed leukocyte count at 660 cells / mL with negative culture (figure 1a). In
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June 2009, he had a dental extraction for a dental abscess, without antibiotic prophylaxis. One
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month later, the patient had an increasing right knee pain associated to an increased volume of
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the right knee, without fever. At admission, laboratory findings showed an increase of C-
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reactive protein level (142 mg/L) associated with blood cells count of 24 10.9 /L. A prosthesis
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infection was suspected, and a two-step surgery was decided. On the 23rd July, the prosthesis
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was removed, synovectomy and curettage were performed, and a spacer was implanted. On
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the knee fluid and on 3 synovial biopsies, direct examination after Gram stain reaction
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displayed numerous polynuclear neutrophils and Gram positive cocci in chains. Tissues were
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homogenized in a mini bead-beater (MM200 Retsch, Germany) and cultivated onto blood and
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chocolate agar plates and brain heart infusion broth (Oxoid). Cultures on chocolate agar plates
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yielded alpha hemolytic colonies under aerobic atmosphere. Gram stain reaction performed
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on colonies showed Gram positive cocci in chains (figure 2), but the microorganism could not
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be identified reliably by the phenotypic methods. The identification of the isolate was given
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by 16S rRNA gene amplification as previously described (Jacquier et al., 2010). The
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sequence of the corresponding amplicon was submitted to the NCBI database (access number
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D50540) and showed 99.9% identity with Granulicatella adiacens. Antibiotic susceptibility
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of the isolate was tested using disc diffusion method and MICs were determined using E-test
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method, according to the EUCAST guidelines (www.eucast.org). The isolate was susceptible
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to beta-lactams, macrolides, rifampicin, aminoglycosides and glycopeptides; and resistant to
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sulfamethoxazole/trimethoprim. The MIC measurement displayed low MICs for amoxicillin
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(MIC < 0.016 mg/L) and rifampicin (MIC < 0.002 mg/L), and a moderate activity
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oflevofloxacin (MIC = 0.5 mg/L). An antimicrobial therapy combining amoxicillin 2g tid and
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rifampicin 600 mg lid was initially administered intravenously the first two weeks and by oral 2
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route the three following months (until October 2009). One month after the end of
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antimicrobial chemotherapy, total knee prosthesis was reimplanted on November 2009.
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Cultures performed on knee fluid and 5 biopsies remained sterile. Two years later, the patient
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remains clinically well without any inflammatory syndrome (Figure1b).
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Discussion
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Joint prosthesis infections after dental cares are mainly due to Gram positive cocci (more than
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70% of cases), particularly to Staphylococcus spp. and various species of streptococci (Bauer
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et al., 2007). Granulicatella adiacen, a low virulence bacteria, belongs to Nutritionally
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Variant Streptococci (NVS) and is present in the oral flora. This microorganism requires
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pyridoxal or other nutritionally agents into standard media for successful laboratory isolation
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(Ruoff, 1991). Moreover, low metabolic activity and/or biochemical variability of this
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bacterium could lead to misidentification with conventional phenotypic methods. Rate of
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infections due to G. adiacens is probably underestimated, regarding difficulties encountered
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both in culturing and identification. This microorganism has mostly been identified in
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bloodstream and endovascular infections, such as infective endocarditis (Chang et al., 2008;
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Senn et al., 2006), and rarely in osteoarticular infections. G. adiacens has been reported in
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vertebral osteomyelitis (Heath et al., 1998) or septic arthritis (Bauer et al., 2007; Hepburn et
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al., 2003; Riede et al., 2004; Rosenthal et al., 2002); and to date, only one study underlines
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the relationship between oral care and arthroplasty infection due to G. adiacens (Bauer et al.,
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2007).
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Recommendations concerning antibiotic prophylaxis during dental care for patients with
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valvulopathy or cardiac valve prosthesis are well defined to prevent infective endocarditis.
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Antibiotic prophylaxis during dental care for patients with joint prosthetic is controversial.
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As a matter of fact, in 2003, the American Dental Association (ADA) and the American
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Academy of Orthopedic Surgeons (AAOS) established recommendations about antibiotic
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prophylaxis during dental procedure with high incidence of bacteraemia (ADA, 2003). These
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recommendations limited antibiotic prophylaxis to patients with joint replacement less than
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two years, inflammatory arthropathies, immunosuppression (denutrition, HIV, diabetes,
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malignancy), previous joint infection, and haemophilia. Conversely, AAOS recommended in
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2009 to extend antibiotic prophylaxis to all total joint replacement patients prior to any
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invasive procedure that may cause bacteraemia (AAOS, 2010). However, this position is
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controversial (Little et al., 2010; Marek & Ernst, 2009; Napenas et al., 2009) and is still a
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point of concern. Indeed, opponents to extended indications of antibiotic prophylaxis argue
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that bacteraemia due to a chronic bad oral hygiene could be more worrying than those due to a 3
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single dental care (Lockhart et al., 2008); and that the risk of antibiotic side effects could be
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more important than their benefit to prevent a supposed bacteraemia during dental cares.
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In our case report, a patient with prosthetic loosening had dental care without antibiotic
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prophylaxis, and developed secondary a prosthetic infection. In addition, even though that the
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delay between dental cares and the suspicion of infection is long, it could be explained by the
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low virulence of the bacteria and we cannot exclude that the patient waited before consulting.
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In case of prosthetic loosening, many wear particles generate an inflammatory reaction, but
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the particles saturate the macrophages and limit their ability to respond to a bacterial
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aggression (Maderazo et al., 1988). In our case, the patient was probably more susceptible to
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infection due to this local immunosuppression and diabetes.
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Overall, the mode of contamination remains unclear: either the silently chronic bacteraemia
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due to the bad oral conditions was responsible of the knee infection, or this infection was
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directly linked to dental cares. Even if this infection occurred after dental cares, no formal
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evidence could validate this assumption, underlining the complexity of antibiotic prophylaxis
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debate.
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Acknowledgments
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This study was supported by Université Paris-Diderot, Paris 7, France. The authors are
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grateful to Fabienne Meunier for excellent technical assistance in molecular methods.
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A preliminary report was presented at the 31st Annual Meeting of The European Bone and
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Joint Infection Society, Montreux, Switzerland, 2012 (submission number 44911)
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Transparency declarations
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None to declare
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References
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Figures:
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Figure 1. a: Arthro-CT scan. Loosening of the total right knee prosthesis is pointed by the arrows. b: Timeline of the patient’s treatment
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Figure 2. a: Alpha-hemolytic colonies of G. adiacens on chocolate plate agar. b: Gram stain reaction of colonies of G. adiacens
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