BacteriologySpecies of Propionibacterium and Propionibacterium acnes phylotypes associated with orthopedic implants☆
Introduction
Propionibacterium spp. are part of the normal skin flora and often considered nonpathogenic. However, they may cause clinically significant infections, particularly after implantation of a foreign body, such as a prosthetic valve, intraocular lens, ventriculoperitoneal shunt, or orthopedic implant (Brook and Frazier, 1999, Jakab et al., 1996). In orthopedic implant infection, this organism is likely to be inoculated at the time of implant placement, thereafter remaining in a relatively quiescent biofilm state (Richards and Emara, 2001, Viola et al., 1997). As Propionibacterium spp. can be isolated as pathogens or contaminants, it can be challenging to determine, simply based on their isolation, into which group they fall. Microbial characteristics that indicate whether the isolated Propionibacterium spp. are a likely cause of orthopedic implant infection versus a colonizing agent would be clinically useful.
Propionibacterium acnes is isolated from human specimens up to 8 times more frequently than are other species of Propionibacterium (Funke et al., 1997). Johnson and Cummins (1972) differentiated types I and II P. acnes based on serologic agglutination and cell wall sugar analysis. McDowell et al. (2005) differentiated types I and II P. acnes by monoclonal antibody typing (McDowell et al., 2005). Furthermore, in their study, phylogenetics analysis of P. acnes based on nucleotide sequencing of the recA housekeeping gene and a more variable hemolysin/cytotoxin gene (tly) demonstrated that types I and II represent distinct lineages or clades. Their investigations have also revealed that strains within the type I clade could be split into two further clusters, known as types IA and IB (McDowell et al., 2005, Valanne et al., 2005). A new P. acnes clase, known as type III has also recently been described (McDowell et al., 2008).
Antigenic and biochemical differences between P. acnes types may yield variations in expression of virulence factors associated with differential pathogenicity. For example, phylotypes IB and II display differences in the expression of putative Christie-Atkins-Munch-Peterson (CAMP) factors (Valanne et al., 2005). No previous studies have described the relationship of Propionibacterium spp. or P. acnes pylotypes to pathogenicity with regard to infections associated with orthopedic implants. In this study, we hypothesized that P. acnes is the most common cause of Propionibacterium orthopedic implant infection, and also that different pylotypes of P. acnes might be differentially distributed amongst isolates associated with infected and colonized orthopedic implants. Using recA and tly sequence analysis, we evaluated the relative frequencies of P. acnes type IA, IB, II, and III associated with removed orthopedic implants, and we correlated these findings with the presence of infection. We studied Propionibacterium isolates recovered using a recently described implant sonication technique (Trampuz et al., 2007).
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Study subjects and definitions
Propionibacterium isolates obtained from patients undergoing removal of a total hip, knee, shoulder, or spine implant for aseptic failure or presumed infection were collected between February 2005 and October 2007 at Mayo Clinic, Rochester, MN. The medical records of the subjects were reviewed. This study was approved by the Mayo Clinic Institutional Review Board. Some of the patients described in this study were included in a previously published report (Trampuz et al., 2007).
Patients were
Isolates and study population
Sixty-four Propionibacterium isolates from 62 patients were studied. Two patients did not give consent for review of their medical record for research (Minnesota statute 144.335) and were excluded from further analysis. Of the 62 remaining isolates from 60 patients, 26 were recovered from spine, 13 from knee, 12 from hip, and 11 from shoulder implants. P. acnes accounted for 61 of the 62 isolates; P. avidum was present in a single case from an infected shoulder implant.
Of the 61 P. acnes
Discussion
Most published reports about Propionibacterium spp. have involved juvenile acne vulgaris and healthy persons (Gehse et al., 1983, Gloor and Franke, 1978). In subjects with acne, P. acnes is the most common Propionibacterium spp. isolated, followed by Propionibacterium granulosum and P. avidum (Lentze et al., 1979). Little information is available on Propionibacterium spp. and orthopedic implants. Using 16S rRNA based gene sequencing, we identified species of Propionibacterium recovered from
Acknowledgments
The authors thank Melissa J. Jacobson for processing and collection of isolates and Jose Luis del Pozo, MD, PhD, for his thoughtful review of the manuscript.
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Supported by Marques de Valdecilla Foundation (Cantabria, Spain), and the Arthritis Foundation.