Clinical trial NCT03717090: Rapid Diagnosis of Prosthetic Joint Infection by Matrix-assisted Laser Desorption
Official title: Rapid Diagnosis of Prosthetic Joint Infection by Matrix-assisted Laser Desorption Ionization Time-of-flight Mass Spectrometry
Study type: OBSERVATIONAL
Overall status: COMPLETED
Conditions: Prosthetic Joint Infection
Keywords: mass spectrometry, diagnosis, prosthetic joint infection, matrix-assisted laser desorption ionization
Lead sponsor: Chang Gung Memorial Hospital
Sponsor class: OTHER
First posted: 2018-10-24
Enrollment: 80
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: yes
Observational model: COHORT
Time perspective: PROSPECTIVE
Sampling method: PROBABILITY_SAMPLE
Study population: The synovial joint fluid will be sampled before the arthrotomy at the operation room. Aspirates will be collected under an aseptic technique with an 18-Fr sterile syringe with a minimum amount of 14 cc. The sample was partitioned between two set of aerobic and anaerobic BCBs (at least 2.5cc for each bottle), wound culture tube (2cc), synovial fluid analysis (2cc). In instances where there is insufficient fluid to send all 3 modalities (less than 14 mL), patients will be excluded from the current investigation. Samples will be delivered to the clinical microbiology laboratory within a 2-hour period.

Brief summary: This is a prospective cohort study. All patients presenting for periprosthetic joint infection and requiring debridement only or resection arthroplasty will be eligible. The synovial joint fluid will be sampled before the arthrotomy at the operation room.

The purpose of this study will be to evaluate that 1) the concordance of organism identification by the direct identification of MALTI-TOF MS versus routine identification of MALTI-TOF MS and conventional cultures and 2) the timing of preliminary strain identification by the direct identification of MALTI-TOF MS, routine identification of MALTI-TOF MS and conventional cultures in patients with periprosthetic joint infection.

Detailed description: Material and Methods

1. Patients who have a high probability of infection based on the Musculoskeletal Infection Society (MSIS) criteria and are scheduled for debridement only or debridement with implant removal, will be invited to enroll the study after signed informed consent.

   The synovial joint fluid will be sampled before the arthrotomy at the operation room. Aspirates will be collected under an aseptic technique with an 18-Fr sterile syringe with a minimum amount of 14 ccs. The sample will be divided between MALDI-TOF mass spectrometry in standard blood culture bottles (10 ccs), wound culture tube (2 ccs), and synovial fluid analysis (2 ccs). The samples will be delivered to microbiology laboratory within a 2-hour period.
2. Bacterial culture and conventional identification Bacterial identification will be performed by the conventional method using the Vitek 2 system. For the conventional culture, 1 µL of well-mixed synovial joint fluid will be inoculated and spread onto blood agar plates and MacConkey agar plates using a sterile plastic disposable loop. Plates will be incubated in an aerobic atmosphere at 37℃ for 18-24 hr. When bacterial growth is observed, the colonies on blood agar will be counted, and colonies from both types of plates will be identified by using the Vitek 2 system.
3. MALDI-TOF MS identification The suspension obtained following the above sample preparation will be centrifuged at 13,000g for 2 minutes, and the supernatant will be discarded. The pellet will be centrifuged at 13,000g for another 2 minutes prior to the removal of the residual ethanol. Fifty microliters of formic acid (70% v/v) and 50 mL of 100% acetonitrile will be added to the pellet, and mixed thoroughly after each reagent is added. The suspension will be centrifuged again at 13,000g for another 2 minutes, and 1 mL of the supernatant will be spotted onto the steel target plate. Analysis will be performed following air-drying of 1 mL a-cyano-4-hydroxycinnamic acid matrix solution placed onto the dried sample spot in duplicate.

   Mass spectra profiles will be acquired using a microflex LT MALDI-TOF mass spectrometer (Bruker Daltonics, Bremen, Germany) following the manufacturer's settings. Spectra will be recorded in the linear positive mode at a laser frequency of 60 Hz within a mass range from 2000 Da to 20,000 Da. All bacteria identifications will be performed by MALDI-TOF Biotyper RTC and the Bruker MALDI Biotyper 3.1 software and library (4613 isolates; Bruker Daltonics). Criteria used for microorganism analysis and identification will be as recommended by the manufacturer.
4. Statistical analysis Time to identification will be determined as the time from colony formation to the time at which the final result is reported to a physician. Statistical analysis will be performed to compare the three methods using Chi-square tests. The level of statistical significance will be set at p \< 0.05.

Eligibility criteria: Inclusion Criteria: high probability of infection based on the Musculoskeletal Infection Society (MSIS) criteria and will be scheduled for debridement only or debridement with implant removal

Exclusion Criteria:

* Patients not meeting MSIS criteria
* Patients undergoing aseptic revision
* Insufficient synovial fluid amount for analysis.

Primary outcomes:
measure: The identification rate of microorganisms
timeFrame: Immediate post-operative period (usually within 5-7 days following surgery)
Secondary outcomes:
measure: The timing of organism identification
timeFrame: Immediate post-operative period (usually within 5-7 days following surgery)
Other outcomes:
Locations:
city: Kaohsiung
country: Taiwan
facility: Kaohsiung Chang Gung Memorial Hospital
Study officials:
affiliation: Chang Gung Memorial Hospital
name: Feng-Chih Kuo, MD
role: STUDY_CHAIR
References:
citation: Peersman G, Laskin R, Davis J, Peterson M. Infection in total knee replacement: a retrospective review of 6489 total knee replacements. Clin Orthop Relat Res. 2001 Nov;(392):15-23.
citation: Fink B, Makowiak C, Fuerst M, Berger I, Schafer P, Frommelt L. The value of synovial biopsy, joint aspiration and C-reactive protein in the diagnosis of late peri-prosthetic infection of total knee replacements. J Bone Joint Surg Br. 2008 Jul;90(7):874-8. doi: 10.1302/0301-620X.90B7.20417.
citation: Geller JA, MacCallum KP, Murtaugh TS, Patrick DA Jr, Liabaud B, Jonna VK. Prospective Comparison of Blood Culture Bottles and Conventional Swabs for Microbial Identification of Suspected Periprosthetic Joint Infection. J Arthroplasty. 2016 Aug;31(8):1779-83. doi: 10.1016/j.arth.2016.02.014. Epub 2016 Feb 24.
citation: Peel TN, Dylla BL, Hughes JG, Lynch DT, Greenwood-Quaintance KE, Cheng AC, Mandrekar JN, Patel R. Improved Diagnosis of Prosthetic Joint Infection by Culturing Periprosthetic Tissue Specimens in Blood Culture Bottles. mBio. 2016 Jan 5;7(1):e01776-15. doi: 10.1128/mBio.01776-15.
citation: Croxatto A, Prod'hom G, Greub G. Applications of MALDI-TOF mass spectrometry in clinical diagnostic microbiology. FEMS Microbiol Rev. 2012 Mar;36(2):380-407. doi: 10.1111/j.1574-6976.2011.00298.x. Epub 2011 Aug 22.
citation: Haiko J, Savolainen LE, Hilla R, Patari-Sampo A. Identification of urinary tract pathogens after 3-hours urine culture by MALDI-TOF mass spectrometry. J Microbiol Methods. 2016 Oct;129:81-84. doi: 10.1016/j.mimet.2016.08.006. Epub 2016 Aug 5.