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Providing an Evidence Base for Tissue Sampling and Culture Interpretation in Suspected Fracture-Related Infection
M Dudareva1, L K Barrett1, M Morgenstern2
1Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals , Oxford , United Kingdom.
Background:
The recent consensus definition for the diagnosis of fracture-related infection (FRI) includes the identification of indistinguishable microorganisms in at least 2 surgical deep-tissue specimens as a confirmatory criterion. However, this cut-off, and the total number of specimens from a patient with suspected FRI that should be sent for microbiological testing, have not been validated. We endeavored to estimate the accuracy of different numbers of specimens and diagnostic cut-offs for microbiological testing of deep-tissue specimens in patients undergoing surgical treatment for possible FRI.
Methods:
A total of 513 surgical procedures in 385 patients with suspected FRI were included. A minimum of 2 surgical deep-tissue specimens were submitted for microbiological testing; 5 or more specimens were analyzed in 345 procedures (67%). FRI was defined by the presence of any confirmatory criteria other than microbiology. Resampling was utilized to model the sensitivity and specificity of diagnostic cut-offs for the number of surgical specimens yielding indistinguishable microorganisms and for the total number of specimens. The likelihood of detecting all clinically relevant microorganisms was also assessed.
Results:
A diagnostic cut-off of at least 2 of 5 specimens with indistinguishable microorganisms identified by culture was 68% sensitive (95% confidence interval [CI], 62% to 74%) and 87% specific (95% CI, 81% to 94%) for the diagnosis of FRI. Two out of 3 specimens were 60% sensitive (95% CI, 55% to 66%) and 92% specific (95% CI, 88% to 96%). Submitting only 3 deep-tissue specimens risked missing clinically relevant microorganisms in at least 1 in 10 cases.
Conclusions:
The present study was the first to validate microbiological criteria for the diagnosis of FRI, supporting the current confirmatory diagnostic criteria for FRI. Analysis of at least 5 deep-tissue specimens in patients with possible FRI is recommended.
Level Of Evidence:
Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Insights
Validating diagnostic criteria for fracture-related infection (FRI) is crucial. Analyzing at least 5 deep-tissue specimens improves the accuracy of diagnosing FRI, supporting current guidelines.
Area of Science:
- Orthopedics
- Infectious Diseases
- Medical Microbiology
Background:
- The current definition of fracture-related infection (FRI) relies on identifying microorganisms in surgical specimens.
- The optimal number of specimens and diagnostic thresholds for microbiological testing in suspected FRI cases remain unvalidated.
Purpose of the Study:
- To validate the accuracy of different numbers of deep-tissue specimens and diagnostic cut-offs for microbiological testing in patients with suspected FRI.
- To assess the sensitivity and specificity of various specimen numbers for FRI diagnosis.
Main Methods:
- A retrospective analysis of 513 surgical procedures in 385 patients with suspected FRI.
- Resampling techniques were used to model the sensitivity and specificity of diagnostic cut-offs for the number of specimens yielding microorganisms.
- FRI was defined by non-microbiological confirmatory criteria.
Main Results:
- A cut-off of at least 2 of 5 specimens with indistinguishable microorganisms showed 68% sensitivity and 87% specificity for FRI diagnosis.
- Using 2 out of 3 specimens yielded 60% sensitivity and 92% specificity.
- Submitting only 3 specimens risked missing clinically relevant microorganisms in over 10% of cases.
Conclusions:
- The study supports the current microbiological criteria for diagnosing FRI.
- Analyzing a minimum of 5 deep-tissue specimens is recommended for improved diagnostic accuracy in suspected FRI cases.
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