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As reported in contemporary literature, prosthetic joint infection (PJI) caused by Listeria monocytogenes (LM) is a rare infection affecting mainly immunocompromised patients. It is considered a late complication occurring months or years after the arthroplasty that is treated with, or without, implant retention, in one-stage or two-stage surgical procedures, and long-term administration of antibiotics. We reviewed the published studies in the English language and present a case of a patient who underwent total hip arthroplasty (THA) and had been affected by this infection. Our patient was successfully treated with 3 months of antibiotics (ampicillin and TMP/SMX) and a two-stage surgical procedure. The success rates of conservative treatment and one-stage or two-stage procedures are dependent on appropriate patient selection and chronicity of the infection. Ιmmmunocompromised patients are susceptible to PJI caused by LM and should be advised that consumption of unpasteurized dairy products increases the risk of this atypical infection.
Listeria monocytogenes (LM) is a Gram-positive facultative aerobic bacterium initially reported in 1926 during an animal disease epidemic. In the 1980s, it was recognized as a food-borne pathogen that can affect humans. Healthy adults can experience a mild to severe gastroenteritis due to ingestion of highly contaminated food containing up to ∼109 bacteria. However, in the case of immunocompromised individuals, the elderly, pregnant women, and children, even lower levels of contaminated food containing up to ∼102-104 bacteria can cause infection, sepsis, and complications during pregnancy with mortality rates ranging from 20% to 30% [
Lecuit M and Lmonocytogenes Joint and Bone Infections Study Group. Listeria monocytogenes – associated joint and bone infections: a study of 43 consecutive cases.
Lecuit M and Lmonocytogenes Joint and Bone Infections Study Group. Listeria monocytogenes – associated joint and bone infections: a study of 43 consecutive cases.
]. In a study by Charlier et al. it was found that this atypical infection primarily involves prosthetic joints and occurs in immunocompromised patients [
Lecuit M and Lmonocytogenes Joint and Bone Infections Study Group. Listeria monocytogenes – associated joint and bone infections: a study of 43 consecutive cases.
]. However, in recent years, PJI shows an increasing tendency because of an aging population and the increased number of immunocompromised patients undergoing joint replacement surgery [
]. We reviewed the published studies in the English language and present a case of a patient with total hip arthroplasty who had been affected by Listeria monocytogenes (LM).
The patient and his relatives were informed that data concerning the case would be submitted for publication, and they provided their consent.
Case presentation
An 82-year-old woman was admitted to our hospital with a recent history of a progressive right hip pain. She reported gradually increasing hip pain 4 months before her admission to the hospital. At the time of admission, the patient was afebrile, able to walk but in pain which was located at the groin area and radiated to the thigh. The patient had a total hip arthroplasty (THA) performed 9 years ago due to degenerative hip osteoarthritis. Standard hip radiographs demonstrated no obvious loosening signs of the implant (Fig. 1). She reported transitory fever and diarrhea, and that she had consumed soft cheese produced from unpasteurized milk obtained from her own animals. Nevertheless, the patient has been systematically consuming dairy products from her own animals throughout her life. White blood cells (WBCs) were 4.44K/μl, c-reactive protein (CRP) was 0.21mg/dL and erythrocyte sedimentation rate (ESR) 90 mm/1h. Paracentesis of the hip grew Listeria monocytogenes susceptible to aminopenicillins, meropenem, Sulfamethoxazole/Trimethoprim (SXM/TMP). The patient’s medical history also included type 2 non-insulin dependent diabetes, chronic obstructive disease, hyperthyroidism, and hyperlipidemia.
The patient was scheduled for surgical treatment following a two-stage revision of her THA. During the first stage, we found a purulent collection mostly at the posterior aspect of the stem whereas the cup was stable (Fig. 2a and b). At the first stage, we removed the stem using controlled segmentation of the well-fixed part of the stem according to Megas et al [
]; the mobile part and the screws were removed, and a mobile-bearing spacer (Zimmer-Biomet, Warsaw, Indiana) was used (Fig. 3a and b). The patient received intravenous meropenem plus vancomycin for 2 weeks, de-escalated by intravenous ampicillin for 3 weeks, based on the culture results. She was discharged with a combination regimen of oral ampicillin and TMP/SMX and was followed-up until she underwent the second stage revision 3 months later. Before the second stage ESR was 35mm/h and CRP was < 1mg/dl. During the second-stage we removed the mobile-bearing spacer and the cup and, a tantalum cup with a Wagner stem were implanted (Zimmer-Biomet, Warsaw, Indiana). New cultures were negative. Follow-up appointments were scheduled on a monthly basis for the first 6 postoperative months, after a year postoperatively and the last took place 2 years postoperatively. On the last follow-up the patient was asymptomatic (Fig. 4a and b).
Figure 2(a) White row shows pus collection. (b) White row shows the space after removing the pus.
A literature search of the case reports was performed in PubMed and in Google Scholar. The criteria were “THA infection due to Listeria” and “TKA infection due to Listeria”. The keywords used in our search were “Listeria monocytogenes”, “Prosthetic joint infection”, “ΤΗΑ infection due to Listeria” and “ΤΚΑ infection due to Listeria”. Search results were limited to articles written in the English-language. There were 33 publications; 31 were found in PubMed and 2 in Google Scholar where 67 cases were reported (the first one was reported in 1987 and the last one was reported in 2020) (Table 1) [
Lecuit M and Lmonocytogenes Joint and Bone Infections Study Group. Listeria monocytogenes – associated joint and bone infections: a study of 43 consecutive cases.
]. The median age of the patients was 65 y (range, 29-87 y), there were ∼60% males and ∼40% females, 20 patients (30%) had TKA infection whereas 47 patients (70%) had THA infection including our case. All cases were monoarticular infections except 1 case (1.5%) [
]. In addition, all cases were late infections with a mid-time after the arthroplasty of 6.8 years (range, 2 mo-21 y). Our literature research shows that 86.7% of the cases were immunocompromised, 7 patients (10%) reported no underlying medical condition, and furthermore in 2 patients (2.9%) there was no statement [
Lecuit M and Lmonocytogenes Joint and Bone Infections Study Group. Listeria monocytogenes – associated joint and bone infections: a study of 43 consecutive cases.
]. The most commonly reported underlining medical conditions were rheumatoid arthritis followed by diabetes mellitus, malignancy and transplantation cases. All cases revealed signs of local inflammatory responses and raised inflammatory markers. All patients were febrile although 20 patients (29.8%) were reported afebrile. Fluid culture positivity was reported in all except 1 case (1.5%) where the culture was reported negative [
]. All cases involved monomicrobial infections whereas 2 cases (2.9%) s aureus and s epidermis were also reported (Table 2, Table 3). The antibiotics used in most cases were ampicillin or amoxicillin (>90%) in combination with gentamicin (∼50%). Surgical treatment was performed in 62% of the total cases (Table 4).
Table 1Publications of Listeria PJIs from the first in 1987 up to 2020.
Lecuit M and Lmonocytogenes Joint and Bone Infections Study Group. Listeria monocytogenes – associated joint and bone infections: a study of 43 consecutive cases.
To the best of our knowledge, the present review has been the first comprehensive review of all PJIs of THA and TKA caused by LM in the English literature.
Discussion
PJI after total joint arthroplasty is a challenging complication for an orthopedic surgeon to address. Musculoskeletal Infection Society (MSIS) convened a workbook in 2011 and defined the criteria of PJI [
]. As regards the onset time of infection postoperatively, it is classified as acute when <4 weeks (onset) and chronic when >4 weeks after surgery (delayed/low grade). Moreover, in regards to the duration of the symptoms of a hematogenous infection, they are classified as acute when the duration of symptoms is <3 weeks and chronic when the duration is >3 weeks [
]. The origin of hematogenous infection is reported at a rate of 32% as unknown whereas 68% as of known origin; 11% the oral cavity, 2% central venous catheters, 13% heart valves, 5% implantable electronic cardiac devices, 1% the lung, 1% the spine, 1% peripheral venous catheters, 7% the gastrointestinal tract, 12% the urinary tract, 1% other joint prostheses and the skin and 15% soft tissue [
]. Listeriosis, although it is considered as self-limited gastroenteritis, does have the ability to become an invasive organism especially in the case of immunocompromised individuals, the elderly, pregnant women, and children, where even low levels of contaminated food up to ∼102-104 bacteria can cause infection, sepsis, and complications of pregnancy with mortality rates ranging from 20% to 30% [
]. Most recently Paziuk et al, published a case with primary total knee arthroplasty infected with LM who had a history of consuming unpasteurized dairy products [
Lecuit M and Lmonocytogenes Joint and Bone Infections Study Group. Listeria monocytogenes – associated joint and bone infections: a study of 43 consecutive cases.
]. In a recent study of 294 hips and knees, infection caused by LM was reported at a rate of 0.7%. We have found 67 cases with PJI caused by LM in English Literature (from 1987 until 2020) [
Lecuit M and Lmonocytogenes Joint and Bone Infections Study Group. Listeria monocytogenes – associated joint and bone infections: a study of 43 consecutive cases.
] (Table 1). The mid-time from initial surgery to the onset of infection caused by LM in the prior literature was 6.8 years (range, 2 mo-21 y) whereas in this case was 9 years postoperatively (Table 1, Table 2). The age (older than 60 years), underlying diabetes and the presence of foreign material (THA) were the risk factors noted to be present in our patient. We successfully treated our patient with antibiotics (ampicillin and TMP/SMX) over a 3-month period, and a two-stage surgical procedure. We opted not to add an aminoglycoside, considering its nephrotoxicity as our patient had borderline renal function and we preferred TMP/SMX for synergy and its bactericidal effect with periodic monitoring of the complete blood count and renal function. A combination of ampicillin and trimethoprim-sulfamethoxazole has been employed to effectively treat severe listerial meningoencephalitis [
Lecuit M and Lmonocytogenes Joint and Bone Infections Study Group. Listeria monocytogenes – associated joint and bone infections: a study of 43 consecutive cases.
]. However, to the best of our knowledge, this is the first comprehensive review of all PJIs of THA and TKA caused by LM in English literature up to the year 2020. Although the diagnostic algorithm for PJIs caused by LM does not require any special consideration, we believe that a strategy is required when it comes to the treatment since it affects mainly immunocompromised patients. The duration of antibiotic therapy in our study ranges from 2 weeks of intravenous up to 6 months of per os (PO) whereas surgical treatment involves debridement, implant removal, and arthrodesis, as well as one and two-stage revision (Table 4). Ampicillin is generally considered the preferred agent, and gentamicin is added frequently for synergy especially when treating life-threatening cases of Listeria. Patients allergic to penicillin may use meropenem or SMX-TMP. Our literature review shows that 19 patients (28%) treated conservatively were reported to have good results over a 5-month to 23-month follow-up period, though one died due to cardiopulmonary arrest [
Lecuit M and Lmonocytogenes Joint and Bone Infections Study Group. Listeria monocytogenes – associated joint and bone infections: a study of 43 consecutive cases.
]. Cone et al. in a review published in 2001 pointed out that the recommended treatment for prosthetic joint infection caused by LM is ampicillin or penicillin alone or in combination with an aminoglycoside and TMP/SMX or vancomycin for patients allergic to penicillin [
]. Of 9 patients (13.2%) treated with debridement 7 were reported to have good results over a 3-month to 20-month follow-up period, but 2 patients had implants removed later [
]. In 18 patients (26.8%) one-stage revisions were applied and they were all asymptomatic over a 4-month to 3-year follow-up period with no recurrence [
Lecuit M and Lmonocytogenes Joint and Bone Infections Study Group. Listeria monocytogenes – associated joint and bone infections: a study of 43 consecutive cases.
]. Diaz-Dilernia et al. in a recent publication of a case report and cases review, suggest that one-stage revision surgery can be more effective when compared to other surgical procedures, such as a two-stage revision surgery or debridement, antibiotics, and implant retention (DAIR) [
]. They mention that key factors for the successful treatment of one-stage revision surgery for chronic PJI in TKA are preoperative diagnosis, known susceptibility of the microorganism, aggressive debridement after a standardized surgical protocol, and the combination of local and systemic antibiotics (ATB) therapy [
]. Our literature review shows no recurrent cases from one-stage revisions. In 7 patients (10%), two-stage revision shows good results over a 5-month to 2-year follow-up period [
Lecuit M and Lmonocytogenes Joint and Bone Infections Study Group. Listeria monocytogenes – associated joint and bone infections: a study of 43 consecutive cases.
Lecuit M and Lmonocytogenes Joint and Bone Infections Study Group. Listeria monocytogenes – associated joint and bone infections: a study of 43 consecutive cases.
]. Nevertheless, it is an additional surgical procedure compared to one-stage revision. In regards to the surgical treatment of our patient, one-stage or two-stage revision of the THA was debatable. On the basis of our study, the one-stage revision of the THA could have been an equally effective treatment.
Of all patients 19 (28%) were treated conservatively and for 7 (10%) there was no statement (Table 4). We think that the success rates of conservative treatment, one-stage or two-stage procedures are dependent on selecting appropriate patients having considered acute and chronic infections, and other individual factors.
Based on our study, although the number of patients is limited, we believe that PJIs caused by LM after THA and TKA can be treated with debridement and mobile part replacement if the implant is stable or with one-stage procedures with suitable antibiotics (ATB) and proper time administration.
Conclusion
Although the diagnostic algorithm for PJI caused by LM does not require any special consideration, a strategy is vital when considering prevention and treatment since it affects especially immunocompromised patients. Ampicillin is generally considered the preferred agent in combination with gentamicin. Meropenem or SMX-TMP have been suggested for patients allergic to penicillin. A combination of ampicillin and trimethoprim-sulfamethoxazole seems to be an option for severe infections. The time of antibiotic administration, conservative or surgical treatment, debridement and prothesis retain or removal in one or two-stages revision remain controversial. Surgical treatment was performed in 42 patients (62%), 19 patients (28%) were treated conservatively and for 7 (10%) there was no statement. Our literature review shows no recurrent cases from one-stage revisions. The present study shows, that this type of infection can be treated with debridement, and mobile part replacement if it is stable or one-stage revision with suitable antibiotics and proper time administration. Ιmmmunocompromised patients are susceptible to PJI caused by LM and should be advised that consumption unpasteurized dairy products increases the risk of this atypical infection.
Acknowledgment
None
Conflicts of interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
The patient and his relatives were informed that data concerning the case would be submitted for publication, and they provided their consent.
Informed patient consent
The author(s) confirm that written informed consent has been obtained from the involved patient(s) or if appropriate from the parent, guardian, power of attorney of the involved patient(s); and, they have given approval for this information to be published in this case report (series).
Lecuit M and Lmonocytogenes Joint and Bone Infections Study Group. Listeria monocytogenes – associated joint and bone infections: a study of 43 consecutive cases.
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