International

International Orthopaedics (SICOT) (1992) 16:237-239

Orthopaedics © Springer-Verlag 1992

Listeria monocytogenes infection in prosthetic joints E Allerbergerl, M. J. Kasten 2, F. R. Cockerill III2, M. Krismer3, and M. P. Dierichl Federal Pubfic Health Laboratory and Institute of Hygiene, University of Innsbmck, Austria 2Division of Infectious Diseases, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA 3Department for Orthopaedic Surgery, University Clinic of Innsbruck, Austria

Summary. Listeria monocytogenes is increasingly recognised as a cause of prosthetic joint infection. These infections tend to be more insidious and indolent in contrast to similar infections with Staphylococcus aureus. They can occur in patients who are immunocompromised due to malignancy or other illness or in nonimmunocompromised elderly patients. Listeria infections should not be treated with cephalosporins and prolonged antimicrobial treatment is generally advised for prosthetic joint infections. We noted a high affinity of L. monocytogenes for foreign bodies. Three of twenty-seven cases (11%) of listeriosis under the period of investigation were associated with foreign bodies (hip prosthesis, knee prosthesis and arterial graft). R6sum~. Listeria monocytogenes est de plus en plus souvent impliqud dans des infections sur prothbses articulaires, Ces infections ont tendance ~ ~tre plus insidieuses et moins douloureuses que celles gt Staphylococcus aureus. Elles peuvent survenir chez des patients immunoddprimds en raison de cancers ou d'autres maladies, ou chez des sujets ~gds non immunoddprim(s. Un traitement anti-microbien prolong6, autre que par cdphalosporines, est g(ndralement indiqud dans les infections sur prothkses. Sur les vingt-sept cas de listdriose recensds pendant la pdriode d' investigation, trois (11%) dtaient associds gtla prdsence de corps (trangers (prothbse de hanche, prothkse du genou et greffe artdrielle).

plication but may lead to permanent failure of the procedure. Prosthetic joint infections may be considered according to the time of onset of symptoms. While "early infections" occurring during the first post-operative month are considered to be nosocomial, "late infections" are thought to represent a mixture of nosocomial and community-acquired infections. Prosthetic joint infections may be caused by a wide spectrum of bacteria, but Listeria monocytogenes prosthetic infections were not reported prior to 1987 [1]. Recently they have been increasingly recognised as "late infections" and probably represent haematogenous seeding. Listeria monocytogenes is a gram positive, nonspore-forming aerobic rod which is widespread in nature and may produce a variety of syndromes in humans. Listeriosis is most common among the elderly, neonates, immunocompromised individuals, and pregnant females. It may present as an acute meningoencephalitis, as the sepsis syndrome, and it may cause premature labour or foetal death during pregnancy. Localized infections also occur [3, 20, 23]. In this paper we report two cases of prosthetic joint infection with L. monocytogenes and discuss the salient features. Materials and methods Our report has been prepared from the records of two patients treated for prosthetic joint infection due to L. monocytogenes.

Case reports Introduction During the last two decades, hip and knee joint replacement has become a routine procedure in orthopaedic surgery. Infection is an uncommon comReprint requests to: E Allerberger, Institut ftir Hygiene der Universittit Innsbruck, Fritz-Pregl-Strasse 3, A-6020 Innsbrnck, Austria

Patient A. A 64-year-old lady developed sudden severe hip pain five months after a third total hip revision. Her white blood cell count was raised to 20.4 x 109/L with 77% neutrophils and 10% band forms. The hip was explored and 200-300 ml of pus were found deep to the iliotibial band. The prosthesis was removed and the hip debrided. Bacterial cultures grew a pure culture of Listeria monocytogenes. The organism was sensitive to ampicillin but resistant to cephalosporins. Susceptibility testing was performed by agar-dilution [4]. Serological subtyping was not performed. No blood cultures were taken.

238 The patient was treated with 1-2 g of ampicillin intravenously every 6 h for 10 days followed by oral amoxycillin 1 g three times a day for a month. She was doing well with no evidence of recurrence four months after surgery. An 80-year-old lady developed severe pain of one month's duration nine years after a total knee replacement.There was a tender effusion but no other sign of acute inflammation. She was afebrile, but her white blood cell count was 13.5 x 109L and her erythrocyte sedimentation rate 102 mm in 1 h. Further examination revealed anaemia and a colonic carcinoma which had metastasised to the liver. Aspiration of the joint produced 60 ml of pus from which L. monocytogeneswas cultured. The organism was incorrectly reported to be sensitive to the cephalosporins, and susceptibility testing was performed by the Kirby-Bauer disk method [7]. Blood cultures yielded no bacterial growth. The patient was treated with intravenous cefamandole 2 g every 12 h and gentamicin 80 mg every 12 h for 42 days, and then with cefotaxime 3 g every 12 hours and tobramycin 80 mg every 8 h for 4 days. Antimicrobialtherapy was discontinued due to a lack of clinical response. The patient continued to have persistent severe pain and x-rays revealed a dramatic progression of decalcification around the prosthesis. Two months after admission the prosthesis was removed and an arthrodesis of the left knee joint was performed. Post-operatively the patient was treated with 2 g of cefamandole intravenously every 12 h for 12 days followed by oral cefalexin 1 g twice a day for 2 weeks. The external fixator was removed 7 weeks after surgery and she was discharged one week later. The patient died from her underlying malignancy two years after her knee surgery. It was reported that this patient had regularly consumed unpasteurised cow's milk. Patient B.

Discussion In 1926 Murray, Webb and Swann [16] discovered the causative agent of listeriosis in rabbits. Human infection was first reported by Nyfeldt in 1929 [18] and since then Listeria monocytogenes has been isolated and identified with increasing frequency. Infection of prosthetic joints with L. monocytogenes was first reported in 1987 [1] and this problem is being increasingly recognised. A review of the literature by Louthrenoo and Schuhmacher [14], published in 1990, revealed only four cases of prosthetic joint infection by L. monocytogenes in three hips and one knee. By 1991 ten cases had been reported, including the two patients presented in this paper, with six in the hip and four in the knee [ 1, 5, 9, 10, 11, 15, 25, 27]. It is possible that the actual incidence of listeria prosthetic joint infections has not increased but that further awareness of this possibility has led to a more thorough laboratory examination of gram positive bacilli. The clinical presentation of prosthetic joint infection due to L. monocytogenes appears to be more insidious and indolent than the septic arthritis due to the Staphylococcus aureus or to the Streptococcus. This is not surprising given the nature of the organism and the clinical presentation of other infections due to Listeria.

F. Allerberger et al.: Listerial infection ofjoint prosthesis Prognosis in patients with Listeria prosthetic arthritis is good based on these few reported cases. Recovery was complete in six of ten cases. Removal of the prosthesis was required for cure in four cases. The recommended antibiotic treatment is ampicillin or amoxycillin four times a day [12]. Although gentamicin may be used synergistically with ampicillin it should not be used as monotherapy or for long periods. Cephalosporins plus aminoglycosides failed to improve the clinical situation of patient B. Cephalosporins are not effective against Listeria and false in vitro sensitivity reports can result from the use of disk diffusion tests. This is similar to the problem experienced with sensitivity testing of enterococci by disk diffusion. Treatment failures have been documented repeatedly [1, 2, 25, 26] and the use of cephalosporins in known cases of listeriosis is totally contraindicated, There is little information available about the appropriate duration of antibiotic therapy for L. monocytogenes prosthetic joint infection. Regimes similar to that used for patient A lasting 6 weeks appear to be adequate. However, treatment m a y need to be prolonged if recurrence of infection in immunosuppressed patients is to be avoided. Our two cases demonstrate some of the typical features associated with listerial infection. Both patients were elderly and one had an underlying malignancy. Coincidental bowel pathology is a common factor in m a n y cases [21]. However, unlike the majority of L. monocytogenes infections blood cultures are usually negative in cases of prosthetic infections [17]. The source of listeriosis is usually unknown except when transplacental transmission occurs but there is increasing evidence of food-borne transmission. A number of reports have recently appeared implicating vegetables, dairy products, and meat [6]. Regular consumption of unpasteurized milk was recorded for patient B, and the literature supports a role for raw milk consumption in at least two listeria epidemics [2, 23]. Booth et al. recently reported a patient with a prosthetic knee joint infection secondary to L. monocytogenes who also regularly consumed unpasteurized milk [9]. Epidemiological and laboratory studies have implicated processed meats as a cause for listeriosis [22]. In 1989 the USA instituted a zero tolerance policy for L. monocytogenes in ready-to-eat products because of increasing concern regarding the potential for growth of Listeria in processed foods. Studies of stool specimens from normal hosts suggest that the infection is frequently asymptomatic and the frequency of faecal excretors has been investigated in various populations. Bojsen-Moller esti-

F. Allerberger et al.: Listerial infection of joint prosthesis m a t e d that this is a m i n i m u m of 1.2% in a low risk population. Workers in slaughter houses had the higher rate of 4.8% [8]. The true incidence of carriers is p r o b a b l y higher since the organism is difficult to isolate f r o m stools. It appears that m a n y people h a v e contact with and m a y carry the organism, but f e w develop s y m p t o m a t i c infections. T h o s e who do are usually i m m u n o c o m p r o m i s e d . The alteration in the i m m u n e response m a y be simply secondary to age or to the presence o f foreign material in patients with infected joints. F r o m clinical observations [24] and laboratory experiments [19] it is apparent that the m o n o n u c l e a r p h a g o c y t e is very important in the host response to L. m o n o c y t o g e n e s . Foreign material m a y potentiate infection both b y reducing the inoculum of bacteria required to induce inflammation and b y promoting sequestration of bacteria in areas inaccessible to host defences [13]. Bacterial adherence to the prosthetic device m a y also be important in the genesis o f foreign b o d y associated infections. Out of the 27 listeriosis cases noted at the M a y o Clinic f r o m 1985 to 1990 and at the Federal Public Health L a b o ratory in I n n s b r u c k f r o m 1988 to 1991, 10 had occurred during pregnancy or in the neonatal period. Three of the remaining 17 infections were associated with foreign bodies (2 joint prostheses, 1 arterial graft). This high affinity of L. m o n o c y t o g e n e s for foreign bodies has not been previously reported. Listeria m o n o c y t o g e n e s prosthetic joint infection is increasingly recognized. It can occur in patients with increased risk factors such as m a l i g n a n c y as well as in the elderly without other predisposing factors. The microbiologist must be careful not to dismiss routinely as contaminants g r a m positive bacilli found in cultures. F r o m previous reports found in the literature and our o w n data it is clear that L. m o n o c y t o g e n e s infections should not be treated with cephalosporins, and that prolonged antimicrobial treatment is generally required.

References 1. Abadie SM, Dalovisio JR, Pankey GR, Cortez LM (1987) Listeria monocytogenes arthritis in a renal transplant patient. J Infect Dis 156:413-414 2. Allerberger F, Guggenbichler JP (1989) Listeriosis in Austria - Report on an outbreak in 1986. Acta Microbiol Hungarica 36: 149-152 3. Allerberger F, Langer B, Hirsch O, Dierich MP, Seeliger HPR (1989) Listeria monocytogenes cholecystitis. Z Gastroentero127: 145-147 4. Anhalt JP, Washington JA (1985) Antimicrobial susceptibility tests of aerobic and facultatively anaerobic bacteria. In: JA Washington (ed) Laboratory procedures in clinical microbiology. Springer, New York, Berlin Heidelberg Tokyo 5. Arathoon E, Goodman SB, Vosti KL (1988) Prosthetic hip infection caused by Listeria monocytogenes. J Infect Dis 157: 1282-1283

239 6. Armstrong D (1990) Listeria monocytogenes. In: GL Mandell, RG Douglas, JE Bennett (eds) Principles and practice of infectious diseases. Churchill Livingstone, New York Edinburgh London Melbourne 7. Bauer AW, Kirby WM, Sherris JC, Truck M (1966) Antibiotic susceptibility by a standardized single disk method. Am J Clin Patho145:493-496 8. Bojsen-Moller J (1972) Human listeriosis, diagnostic, epidemiological and clinical studies. Acta Pathol Microbiol Scand (Suppl) 229:1 - 157 9. Booth LV, Walters MT, Tuck AC, Luqmani RA, Cawley MID (1989) Listeria monocytogenes infection in a prosthetic knee joint in rheumatoid arthritis. Ann Rheumat Dis 49: 58-59 10. Chirgwin K, Gleich S (1989) Listeria monocytogenes osteomyelitis. Arch Intern Med 149:931 - 932 11. Curosh NA, Perednia DA (1989) Listeria monocytogenes septic arthritis: a case report and review of the literature. Arch Intern Med 149:1207 - 1208 12. Department of Health and Social Security (1989) Listeriosis and food. Circular PL/CMO (89) 3 13. Dougherty SH, Simmons RL (1982) Infections in bionic man: the pathobiology of infections in prosthetic devices. Part I. Curr Probl Surg 29:217-230 14. Louthrenoo W, Schumacher HR (1990) Listeria monocytogenes osteomyelitis complicating leukaemia: report and literature review of listeria osteoarticular infections. J Rheumatol 17:107 - 110 15. Massaroti EM, Dinerman H (1990) Septic arthritis due to Listeria monocytogenes: report and review of the literature. J Rheumatol 17:111-113 16. Murray EGD, Webb RA, Swann MBR (1926) A disease of rabbits characterized by a large mononuclear leucocytosis, caused by a hitherto undescribed bacillus: Bacterium monocytogenes (n. sp.). J Pathol Bacterio129:407-439 17. Nieman RE, Lorber B (1980) Listeriosis in adults: a changing pattern. Report of eight cases and review of the literature 1968-1978. Rev Infect Dis 2:207-227 18. Nyfeldt A (1929) Etiologie de la mononuclrose infectieuse. CR Soc Biol 101:590-593 19. Osebold JW, Pearson LD, Medin NI (1974) Relationship of antimicrobial cellular immunity to delayed hypersensitiity in listeriosis. Infect Immun 9:354- 362 20. Ralovich B (1984) Listeriosis research. Akademiai Kiado, Budapest 21. Samara Y, Altman G, Hertz M (1984) Adult listeriosis - a review of 18 cases. Postgrad Med J 60:267-269 22. Schwartz B, Ciesielski CA, Broome CV, Gaventa S, Brown GR, Gellin BG, Hightower AW, Mascola L, and the Listeriosis Study Group (1988) Association of sporadic listeriosis with consumption of uncooked hot dogs and undercooked chicken. Lancet 2:779 - 782 23. Seeliger HPR (1961) Listeriosis. Hafner, New York 24. Simpson JF, Leddy JP, Hare JD (1967) Listeriosis complicating lymphoma: a report of four cases and interpretive review of pathogenic factors. Am J Med 43: 39-49 25. Thankhiew I, Ghosh MK, Kar NK, Robinson PJ (1990) Septic arthritis due to Listeria monocytogenes. J Infect 20: 324-325 26. Trautmann M, Wagner J, Chahin M, Weinke T (1985) Listeria meningitis: report on ten recent cases and review of current therapeutic recommendations. J Infect 10:107 - 114 27. Weiler PJ, Hastings DE (1990) Listeria monocytogenes An unusual case of late infection in a prosthetic hip joint. J Rheumatol 17:705-707

Listeria monocytogenes infection in prosthetic joints.

Listeria monocytogenes is increasingly recognised as a cause of prosthetic joint infection. These infections tend to be more insidious and indolent in...
356KB Sizes 0 Downloads 0 Views