Clostridium perfringens in a total hip arthroplasty: An unusual cause of prosthetic joint infection, treated with one-stage revision: A case report

Dorien Peters; Linda Martine Kampschreur; Loredana Elena Pirii; Wierd Pieter Zijlstra

doi:10.1016/j.jorep.2024.100350

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Case Report

2024

:3;

100350

doi:

10.1016/j.jorep.2024.100350

Clostridium perfringens in a total hip arthroplasty: An unusual cause of prosthetic joint infection, treated with one-stage revision: A case report

Dorien Peters^a,, Linda Martine Kampschreur^b, Loredana Elena Pirii^c, Wierd Pieter Zijlstra^a

a Department of Orthopedic Surgery, Medical Center Leeuwarden, Henri Dunantweg 2, 8934 AD, Leeuwarden, the Netherlands

b Department of Internal Medicine, Medical Center Leeuwarden, Henri Dunantweg 2, 8934 AD, Leeuwarden, the Netherlands

c Certe Center for Infectious Diseases Friesland, Jelsumerstraat 6, 8917 EN, Leeuwarden, the Netherlands

⁎Corresponding author: Dorien Peters. dorien.peters@mcl.nl

Received: 2023-12-19, Accepted: 2024-5-6, Published: 2024-5-10

The Authors

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Prosthetic Joint Infection (PJI) is a serious complication after total hip arthroplasty (THA). PJI is the most common reason for revision surgery on patients with arthroplasty, leading to prolonged hospitalization, repeated surgical intervention, and sometimes in definitive loss of the implant. Clostridium perfringens causing PJI is highly unusual.

In this case, we describe the diagnostic and therapeutic challenges of a Clostridium perfringens Prosthetic Joint Infection following a total hip arthroplasty in an elderly woman.

This case is unique because it is the first published PJI with C. perfringens, successfully treated by a one-stage infection revision combined with twelve weeks of antibiotics. Despite an extensive work up, a PJI or C. perfringens infection was not proven preoperatively. Perioperative tissue and sonication cultures were the cornerstone of the diagnosis. C. perfringens may be seen as an ‘easy to treat’ pathogen and successful treatment is possible with a one-stage infection revision and additional antibiotics for twelve weeks.

Keywords

Total hip arthroplasty

Prosthetic joint infection

Clostridium perfringens

One-stage revision

Sonication

PJI

C. perfringens

THA

CRP

WBC

ESR

NINJA

haemin/vit K1

MALDITOF

CFU

MIC

1 Introduction

Prosthetic Joint Infection (PJI) is a serious complication that may occur after Total Hip Arthroplasty (THA), leading to prolonged hospitalization, repeated surgical intervention, and implant failure.¹ In the Netherlands, 25 % of revision surgeries were performed due to suspected PJI in 2021.¹ PJI can be divided into three subtypes: early postoperative, late acute hematogenous, and late chronic infection. Depending on the subtype, a different diagnostic approach, intervention, and treatment are indicated.²^,³ Late chronic PJI presents with discomfort, decreased range of movement, sinus formation, and/or discharge. Blood markers of inflammation may be elevated. Examinations of serial X-rays may show the formation of new periosteal bone and/or a radiolucent line, suggesting loosening of the prosthesis.⁴ Around 15 % of prostheses revised for loosening are found to be infected.⁵ The gold standard for treatment of late chronic PJI is two-stage revision surgery and long-term antibiotics. Clostridium perfringens, is an anaerobic gram-positive spore-forming bacillus found in soil and intestines. It can cause histotoxic syndromes, including gas gangrene, necrotizing pancreatitis, food-borne infection, and enteritis necroticans.⁶ To the best of our knowledge, we hereby present the first case report of a PJI caused by C. perfringens, a highly unusual causative agent, that was successfully treated with a one-stage infection revision and antibiotics.

2 Case report

An 85-year-old female patient with a medical history of psoriasis, treated with Methotrexate, received a left THA as treatment for osteoarthritis. The surgical procedure was performed without complications. The patient showed normal signs of wound healing postoperatively.

3 Clinical findings

Two years after the surgery, the patient developed pain in the left hip. Mobility is becoming progressively challenging. Physical examination reveals pronounced discomfort during left hip rotations. No clinical indicators of infection were observed.

4 Diagnostic assessment

One year postoperatively, the X-ray shows a lucent line around the cup (Fig. 1). The blood test showed a C-reactive protein (CRP) of 22 mg/L, a white blood cell (WBC) count of 7.7 × 10^9/L, and an Erythrocyte Sedimentation Rate (ESR) of 37 mm/hr (Table 1). Bone scintigraphy and leukocyte scintigraphy showed no abnormalities. An ultrasound-guided sterile puncture was performed of the hip joint. There was no fluid collection to aspirate; therefore, the joint was flushed with sterile sodium chloride solution and collected. Gram-staining and culture of this material showed some leucocytes but no growth of bacteria. Two years postoperatively, the X-ray showed a progression of the radiolucent line and cortical thickness (Figs. 2 and 3). Bone scintigraphy showed increased activity around the stem, suggesting remodellation or stress shielding. CRP at that time was 15 mg/L, and the WBC count was 7.5 × 10^9/L (Table 1). Leukocyte scintigraphy showed again no signs of infection. At last, a nuclear arthrogram showed loosening of the stem.

X-ray one year postoperatively, a lucent line around the cup is detectable.

Table 1 Bloodmarkers of inflammation. Normal value CRP <5 mg/L, WBC <10 × 10^9/L, ESR <30 mm/hr.

Bloodmarkers inflammation	One year postoperatively primary THA	Two years postoperatively primary THA	Two years postoperatively Revision surgery
CRP (mg/L)	22	15	6
WBC (x 10^9/L)	7.7	7.5	7.0
ESR (mm/hr)	37	–	5

X-ray two years postoperatively, progressive radiolucent line around the cup and cortical thickness is detectable.

X-ray two years postoperatively, cortical thickness seen on the axial plane.

5 Therapeutic intervention

5.1

5.1 Surgery

One-stage revision surgery was planned, based on suspected aseptic loosening of the stem. Preoperatively, 2 g of cefazolin were administered to prevent secondary infections, according to our Northern Infection Network for Joint Arthroplasty (NINJA) protocol.³ Intra-operatively, a low-grade infection was suspected because of vitreous loose-mesh tissue in the psoas muscle region. Eight tissue cultures were taken, each with a clean instrument. The suspect tissue was removed using a diathermic knife. The procedure was converted into a one-stage infection revision of both the cup and the stem and these were sent for sonication. After a complete surgical debridement macroscopically, the hip was soaked in povidone-iodine and then flushed with 6 L of 0.9 % saline using pulse lavage.³^,⁷ Then draping, gloves, and instruments were changed, and a new THA prosthesis was implanted with bone cement containing gentamycin and vancomycin. Because of suspicion of a PJI, the patient started postoperatively with intravenous cefuroxime 1500 mg three times a day.

5.2

5.2 Microbiology

Each tissue sample was inoculated on blood, chocolate agar and Schaedler Anaerobe Agar with Sheep Blood (with Haemin and Vitamin K1) (Thermo Scientific™) and on Brucella broth + haemin/vit K1, a modified medium for enrichment of anaerobes and suspensions of anaerobes for testing antimicrobial susceptibility.⁷ The enrichment medium was inoculated on blood, chocolate agar and Schaedler Anaerobe Agar with Sheep Blood (with Haemin and Vitamin K1) after seven days incubation or earlier if signs of bacterial grow were seen. Sonication of cup and stem was used to separate adherent bacterial colonies in biofilm and to try to improve microbiological diagnostic yield. Aerobic and anaerobic plates were incubated at 37 °C for fourteen days. Equal aliquots of sonication fluid (10 ml) were inoculated into Bactec aerobic and anaerobic bottles (BD Diagnostics, Sparks, MD). Bactec bottles were incubated at 37 °C for fourteen days or until they flagged positive. Positive Bactec bottles were subcultured onto agar, and isolates were identified by matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) mass spectrometry (Vitek MS Biomerieux). Drug susceptibility testing was performed using E-tests (Biomerieux) and interpreted using EUCAST breakpoints. Conforming to existing guidelines, positive tissue sample culture was defined as the isolation of indistinguishable organisms (with identical drug susceptibility profiles) from two or more independent tissue specimens and positive sonication culture as ≥50 CFU per milliliter (Colony Forming Unit/ml).⁸^,⁹ In this case, the anaerobic bottle of the inoculated sonication fluid of the cup flagged positive for C. perfringens. In one (cup) of the two sonicated materials (cup and stem) C. perfringens was found. Further, three of eight tissue cultures were positive for C. perfringens. All of them were anaerobic cultures. C. perfringens was tested sensitive to benzylpenicillin (minimum inhibitory concentration (MIC) 0.25 mg/l and MIC 0.125 mg/l), vancomycin (MIC 0.25 mg/l) and metronidazole (MIC 0.38 mg/l) and resistant to clindamycin (MIC >256 mg/l). Antibiotics were switched from cefuroxime to intravenous benzylpenicillin twelve million units a day. In total, the patient received two weeks of intravenous antibiotics, followed by oral amoxicillin 750 mg three times a day for ten weeks.

6 Follow-up and outcomes

Two years after the revision surgery, the left hip was pain-free without any clinical signs of infection. The X-ray showed pre-existent cortical thickening around the stem, but no signs of complications. The blood test showed a CRP of 6 mg/L, a WBC count of 7.0 × 10^9/L and an ESR of 5 mm/hr (Table 1).

7 Discussion

To the best of our knowledge, this is the first published case of PJI with C. perfringens in a patient with a THA, treated by a one-stage infection revision and a twelve-week course of intravenous and oral antibiotics.

7.1

7.1 Previous reports

There are eight other case reports that have been published with PJI due to C. perfringens, resulting in a clinical cure after two-stage infection revision and antibiotics.⁶ Five cases were related to hip prostheses, with onset varying from six weeks to four years postoperatively. Most cases did not describe bacteremia or a clear source of infection, but three had a clear source in the biliary system.

7.2

7.2 Infection

A few possibilities for the spread of C. perfringens were considered: during the surgery, during the puncture, hematogenic, or through the left paracolic gutter spread to the pelvic area.¹⁰ Another possibility is increased gut permeability, which may be associated with PJI and is also described as the gut-immune-joint axis, where a loss of mucosal barrier function may affect antigen trafficking.¹¹ Based on the perioperative findings of loose-mesh tissue around the muscular psoas, it is expected that the low-grade infection has spread through the left paracolic gutter to the muscular psoas. During hospitalization, an abdominal ultrasound was performed to investigate the origin of the infection, but it showed no abnormalities, especially not of the biliary tract.

7.3

7.3 Diagnostics

The first work-up, one year postoperatively, showed signs of loosening without signs of infection. Revision surgery was not performed at the request of the patient. Because of persistent pain, a second work-up two year postoperatively was performed without signs of infection, which led to the planned one-stage, aseptic stem revision surgery. In cases where the bone scintigraphy and/or the leukocyte scan return negative, an infection is highly unlikely, where bone scintigraphy has the highest sensitivity. The best diagnostic test to determine a PJI is a joint aspirate of synovial fluid, which in this case showed no bacteria.⁷ This highlights that C. perfringens is a difficult-to-detect pathogen.

7.4

7.4 Microbiology

The perioperative cultures were the cornerstone of the diagnosis of the infection with C. perfringens, because of the use of sonication, which can reveal different and more sensitive results than tissue cultures do.¹² Next to this, it illustrates the importance of sampling multiple cultures and the added value of sonication and enrichment medium. C. perfringens may be seen as an ‘easy to treat’ bacteria.³

7.5

7.5 Conclusion

This case presents successful treatment for a PJI with C. perfringens, by a one-stage infection revision and a twelve week course of antibiotics. Recommendations are: (1) In a PJI with difficult-to-detect pathogens, it is crucial to perform both tissue and sonication cultures to receive reliable microbiological results. (2) One-stage infection revision and twelve weeks of antibiotics may be sufficient treatment for a PJI with C. perfringens as an ‘easy to treat’ bacteria.

Financial support and sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Informed consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images.

Ethical statement

Ethical approval was not required for this study.

CRediT authorship contribution statement

Dorien Peters: contributed to the project by, Conceptualization, writing, critical revision. Linda Martine Kampschreur: contributed by writing, critical revision. Loredana Elena Pirii: contributed by critical revision. Wierd Pieter Zijlstra: contributed by, Conceptualization, writing and critical revision, All authors have edited, read and approved the final manuscript.

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