Summary: In a 5-year period, 73 coryneform isolates from prosthetic joint and open fracture infections in 60 patients treated in a hospital specialized in orthopedic surgery were speciated. The most frequent species wereCorynebacterium amycolatum, Corynebacterium striatum, Corynebacterium diphtheriae biotypemitis, andCorynebacterium jeikeium. At least 14 isolates were deemed clinically significant as sole agents of infectio

Frommelt, L.

Funke, G.

Pünter-Streit, V.

von Graevenitz, A.

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Brief Report A. yon Graevenitz, L. Frommelt, V. Ptinter-Streit, G. Funke Diversity of Coryneforms Found in Infections following Prosthetic Joint Insertion and Open Fractures Summary: In a 5-year period, 73 coryneform isolates from prosthetic joint and open fracture infections in 60 patients treated in a hospital specialized in orthopedic surgery were speciated. The most frequent species were Corynebacterium amycolatum, Coryne- bacterium striatum, Corynebacterium diphtheriae biotype mitis, and Corynebacterium jeikeium. At least 14 isolates were deemed clinically significant as sole agents of infection. Introduction Infections following prosthetic joint insertion and open fractures have been reviewed in the immediate past by various authors [e.g., 1-5]. We have been surprised, how- ever, about the paucity of coryneform organisms reported in such infections. The main agents have been coagulase- negative and -positive staphylococci, followed by various streptococci and gram-negative rods [1-5]. A few reports have mentioned "anaerobic orynebacteria" [6] or Propi- onibacterium acnes [4], some have reported non-speciated "diphtheroids" [1, 2], and a few did not find any such bac- teria [3, 5]. In our pursuit of infections with coryneforms [7], we thought it worthwhile to speciate a collection of coryneforms that one of us (L. F.) has isolated from those infections ince 1992. Patients and Methods All patients reviewed had been admitted to the Endo Clinic in Hamburg, Germany, either for an exchange operation ecessi- tated by infection of a prosthetic joint or for correction of an infected open fracture (exogenous osteomyelitis). Generally, apreoperative aspirate was taken from the infected area, material was scraped from the area of infection intraoperatively and postoperatively; drainage fluid was obtained as well. All samples were Gram-stained, inoculated into Brain Heart Infusion (bioM6rieux, Marcy I'Etoile, France), TVLS Medium [8], the set of media devised by Lodenki~rnper [9], aerobic (5% CO2) Co- lumbia blood agar, and anaerobically incubated Brucella Agar, both with 5% sheep blood (bioMfirieux). If there was growth in the liquid media [8, 9], they were subcultured to those aerobic and anaerobic blood agar plates as well. Isolates were kept on Brain Heart Infusion (bioM~rieux) slants. They were identified as to species by a scheme laborated by two of us [10]. Suscepti- bility testing was done by the DIN method [11]. Clinical significance of the isolates was evaluated from the pa- tients' records. All patients howed clear signs of infection as de- fined in an earlier study [6]. We judged as clearly significant those isolates that were found as monocultures in aspirates (most of these had been positive on direct Gram stains). Questionable significance was assumed when coryneforms were isolated from scrapings or drains only. Mixed cultures were not- ed, but were not further evaluated for significance. Results In all, 73 isolates were recovered from 60 patients in a 5-year period (Table 1). Fourty-one came from hip infec- tions, 17 from knee infections, and 15 from variously locat- ed exogenous osteomyelitides. Fourteen isolates were deemed significant, 16 were deemed to be of questionable significance, and 43 were mixed with staphylococci, strep- tococci, and/or aerobically or anaerobically growing gram- negative rods. Since our patients were referred from other hospitals, we were unable to determine whether prostheses previously placed contained antibiotics or not. For the same reason, incubation periods could not be determined with certain- ty; they varied from a few weeks to 2 years. At the Endo Clinic, no antibiotic prophylaxis was given for exchange operations (which involved antibiotic-impregnated acrylic cement) [6]. Nevertheless, 22 patients had received antibi- otics for post-primary infections which we defined as those that were preceded by earlier (primary) ones. There were 39 primary and 34 post-primary infections. The most frequent species involved was Corynebacteriurn amycolaturn. Most isolates of this species were formerly classified as Corynebacterium xerosis [7]. This species is frequently multiresistant [7], particularly to those anti- biotics often used in orthopedics (clindamycin, aminogly- cosides, rifampin, and sometimes also to [3-1actam antibio- tics). The same may be true for the second most frequent species, Corynebacterium striaturn [7], except that it is generally susceptible to [3:lactams. Also often multiply antibiotic-resistant is the fourth most frequent species, Corynebacterium jeikeium [7]. It is interesting to note that all coryneforms i olated from the 22 patients who received preoperative antibiotics were multi-resistant. Received: 18 August 1997/Accepted: I7 November 1997 Prof. Dr. A. yon Graevenitz, Verena Piinter-Streit, Dr. reed. G. F, mke, In- stitut f~ir Medizinische Mikrobiologie tier Universit~t Z irich, Gloriastr. 30, CH-8028 Ztirich, Switzerland; Dr. med. L. Frommelt, Mikrobiologi- sches Labor, Endo-Klinik D-22767 Hamburg, Germany. 40 / 36 Infection 26 (1998) No. l 9 MMV Medizin Vcrlag GmbH Mtinchen, Mtinchen 1998 A. von Graevenitz et al.: Coryneforms in Orthopedic Infections Table 1" Coryneform bacteria from orthopedic infections. Species Clinically significant a)Hip Knee Osteo- Hip myelitis a) pb) ppb) p pp p pp p pp Mixed Of questionable significance Knee Osteo- Hip Knee Osteo- Total per myelitis myelitis species P PP P PP P PP P PP P PP Corynebacterium c) amycolamm 0 2 0 1 0 0 3 4 Corynebacterium striatum 2 1 1 0 1 1 3 4 Corynebacterium diphtheriae 0 0 0 0 0 0 2 1 Corvnebacterium jeikeium 0 1 0 0 0 0 0 1 Corynebacterium Group G-1 0 0 0 0 0 0 1 0 Propionibacterium sp. 1 1 0 0 0 0 l t Corynebacteriurn sp. c) 0 0 1 0 0 0 0 0 Arthrobacter sp. 0 0 0 0 1 0 0 0 Corynebacterium sp. c) 0 0 0 0 0 0 l 0 Corynebacterium glucuronolyticum 0 0 0 0 0 0 0 0 Dermabacter hominis 0 0 0 0 0 0 i 0 Gordona sp. 0 0 0 0 0 0 0 0 Tsukarnurella sp. 0 0 0 0 0 0 0 0 Aureobacterium sp. 0 0 0 0 0 0 0 0 Corynebacwrium pseudodiphtheriticum 0 (1 0 0 0 0 0 0 t 3 1 3 0 2 0 0 1 1 22 0 l 0 2 1 2 0 0 0 0 19 2 0 1 0 0 0 1 0 0 0 7 0 0 I 2 0 0 I 0 0 0 6 1 0 0 0 2 0 1 0 0 0 5 0 0 0 0 0 1 0 0 0 0 5 ' 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 t 0 0 0 0 0 0 0 0 0 0 1 I 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 l 1 0 0 0 0 0 0 0 0 0 1 l 0 0 0 0 0 0 0 0 0 1 , 0 0 0 0 0 t 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 1 a) see text; b) p = primary, PP = post-primary; c)unable to speciate. The third most frequent species was, surprisingly, Coryne- bacterium diphrheriae. Although this will be the subject of a separate report, it should be ment ioned here that the bi- otype of all isolates except one (gravis) was mitis, and that the ribotypes and antibiogram type corresponded to those found earlier in Switzerland [12]. Table 1 also lists further coryneforrns, each of which was represented by one isolate only. Conc lus ion  The l iterature on the subject lists only four single reports of coryneform osteomyelitis on the extremities in which species were determined [13-16]. Four further reports are extant on cases of septic arthritis [17-20]. Our  report shows that coryneforms are not rare in prosthetic joint in- fections and post-fracture osteomyelit ides and that they may be causative agents in such infections. Acknowledgement  We thank Pala Das, can& reed., for submitting and keeping the strains. References  1. Fitzgerald, Jr., R. H., Peterson, L. F. A., Washington lI, J. A., van Scoy, R. E., Coventry, M. B.: Bacterial colonization of wounds and sepsis in total hip arthroplasty. J. Bone Joint Surg. 55-A (1973) 1242-1250. 2. lnman, R. D., Gallegos, K. V., Brause, B. D., Redecha, P. B., Christian, C. L.: Clinical and microbial features of prosthetic joint in- fection. Am. J. Med. 77 (1984) 47-53. 3. Powers, K. A., Terpenning, M. S., Voice, R. A., Kanffman, C. A.: Prosthetic joint infections in the elderly. Am. J. Med. 88 (1990) 9N-13N. 4. Dietz, F. R., Koontz, F. P., Found, E. M., Marsh, J. L.: The impor- tance of positive bacterial cultures of specimens obtained uring clean orthopaedic operations. J Bone Joint Surg. 73-A (1991) 1200-1207. 5. Bliss, I). G., McBride, G. G.: Infected total knee artbroplasties. Clin. Orthop. Relat. Res. 199 (1985) 207-214. 6. Buchholz, H. W., Elson, R. A., Engelbrechl, E., Lodenk~mper, H., R6ttger, J., Siegel, A.: Management of deep infection of total hip re- placement. J. Bone Joint Surg. 63-B (1981) 342-353. 7. Funke, G., yon Graevenitz, A., Clarridge HI, J. E., Bernard, K. A.: Clinical microbiology ofcoryneform bacteria. Clin. Microbiol. Rev. 10 (1997) 125-1.59. 8. Caselitz, F. H., Freitag, V.: Halbfliissiges Kombinationsmedium (TVLS-Medium) zur Ztichtung anaerober Rakterien. Aerztl. I.ab. !5 (1969) 426-430. 9. Lodenkiimper, H., Stienen, G.: ZurDlerapic anaerober Infektionen. Dtsch. med. Wschr. 81 (1956) 1226-123!. t0. yon Graevenitz, A., Funke, G.: An identification scheme for rapid[y and aerobically growing ram-positive rods Zbl. Bakt. 284 (1996) 246--254. 11. DIN Deutsches lnstitut fiir Normung e.V.: Empfindlicbkeitsprtifung yon Krankheitserregern gegen Chemotherapeutika. DIN 58940 und Infection 26 (1998) No. 1 9 MMV Meclizin Verlag GmbH Mtmchen, Mtinchen 1998 37/41 A. yon Graevenitz et al.: Cowneforms in Orthopedic  Infections 58944. DIN-Taschenbuch 222: Medizinische Mikrobiologie und Im- munologie. Normen und weitere Unterlagen. 2. Auflage. Beuth- Verlag GmbH, Berlin und K61n 1992, pp. 331-403. 12. Gruner, E., Opravil, M., Altwegg, M., yon Graevenitz, A.: Nontoxi- genic Corynebacteriurn diphtheriae isolated from intravenous drug users. Clin. Infect. Dis. 18 (1994) 94-96. 13. Claeys, G. Verschraegen, G., Desmet, L., Verdonk, R., Claessens, H.: Corynebacteriurn JK (Johnson-Kaye strain) infection of a Ktintscher-nailed tibial fracture. Clin. Orthop. Relat. Res. 202 (1986) 227-229. 14. Chomarat, M., Breton, P., Dubost, J.: Osteomyelitis due to Coryne- bacterium group D2. Europ. J. Clin. Microbiol. Infect. Dis. 10 (1991) 43. 15. Weller, T. M. A., McLardy Smith, P., Crook, D. W.: Corynebacte- riurn jeikeium osteomyelitis following total hip joint replacement. J. Infect. 29 (1994) 113-114. 16. Poilane, I., Fawaz, F., Nathanson, M., Cruaud, P., Martin, T., Collignon, A., Gaudelus, J.: Corynebactermm diphtheriae osteomye- litis in an immunocompetent child: a case report. Eur. J. Pediatr. 154 (1995) 381-383. 17. Guran, Ph., Mollaret, H.-H., Chatelain, R., Gropman, M., Prigent, F., B~al, G.: Arthrite purulente h bacille diphth6rique atoxig~ne.- Arch. franq. P6diat. 36 (1979) 926-929. 18. Valenstein, P., Klein, A., Ballow, C., Greene, W.: Corynebacterium xerosis eptic arthritis. Am. J. Clin. Pathol. 89 (1988) 569-571. 19. Booth, L. V., Richards, R. H., Chandran, D. R.: Septic arthritis caused by Corynebacteriurn xerosis following vascular surgery. Rev. Infect. Dis. 13 (1991) 548-549. 20. Damade, R., Pouchot, J., Delacroix, I., Boussougant, Y., Vinceneux, P.: Septic arthritis due to Corynebacterium diphtheriae. Clin. Infect. Dis. 16 (1993) 446-447. 42/38  Infection 26 (1998) No. 1 9 MMV Medizin Verlag GmbH Manchen, Mtinchen 1998 

Diversity of coryneforms found in infections following prosthetic joint insertion and open fractures

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Diversity of coryneforms found in infections following prosthetic joint insertion and open fractures

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