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Enterococci in orthopedic infections: who is at risk?
© Uckay et al; licensee BioMed Central Ltd. 2015
Published: 16 June 2015
Orthopedic and trauma surgery is most frequently a clean surgery, unless injury-related or in the presence of spontaneous soft tissue infection. International guidelines recommend 1st and 2nd generation cephalosporins for perioperative prophylaxis; the later do not cover enterococci.
To investigate whether some patient populations/types of surgery would be particularly at risk for enterococcal infections and might benefit from an adapted prophylaxis.
Single-center, retrospective cohort study of adult patients operated for orthopedic infections 2004-2014. Only intraoperative microbiological samples and first clinical infectious episodes were considered for analysis. We excluded recurrent infections and pediatric cases.
Among 2740 surgical interventions, enterococci were identified in 100 (3.6%) intraoperative samples. Only 33/100 (33%) infections were monomicrobial. Overall, 665 surgeries (24%) involved osteosynthesis material. Enterococcal infections were particularly related to the foot (29/429 vs. 71/2311; p<0.01), associated with abscesses (25/1070 vs. 75/1670; p<0.01), polymicrobial infections (67/572 vs. 33/1853; p<0.01) and underlying osteosynthesis material (35/665 vs. 55/2075; p<0.01). All hardware (total joint arthroplasties, plates, nails) were equally infected without predilection for a particular material. The proportion of enterococci among all pathogens in diabetic foot infections was 7%. Enterococci significantly more often responsible for diabetic foot infections (48/659 vs. 52/2081; p<0.01) and infections among elderly people (median age 65 years vs. 56 years, p<0.01). In contrast, enterococci were almost never identified in septic bursitis and native bone or joint infections. By multivariate analysis adjusting for case-mix and age, the presence of diabetic foot (odds ratio 1.9, 95%CI 1.2-2.9) and polymicrobial infection (OR 6, 95%CI 3.9-9.4) were the only variables significantly associated with enterococcal infection; while sex, age, type of material, and the exposure to antibiotic therapy prior to intraoperative sampling were not.
Enterococci in orthopedic surgery are rare and mostly encountered as co-pathogens in polymicrobial infections of the ulcerating diabetic foot. There is no indication to change our antibiotic prophylaxis policy.
Disclosure of interest
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 cited. 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.