title: Staphylococcus aureus small colony variants in prosthetic joint infection.
abstract: BACKGROUND
  Small colony variants of Staphylococcus aureus tend to persist despite antimicrobial therapy, especially when involved in implant-associated infections.
  
  
  METHODS
  We analyzed 5 cases of hip prosthesis-associated infections due to small colony variants, including their course prior to identification of the pathogen. Biopsy investigations included microbiological examination and, in 1 case, transmission electron microscopy to detect intracellular bacteria in nonprofessional phagocytes. A treatment concept was elaborated on the basis of a published algorithm and patients were managed accordingly.
  
  
  RESULTS
  The patients' mean age was 62.2 years. All patients experienced treatment failures prior to isolation of small colony variants, despite as many as 3 surgical revisions and up to 22 months of antibiotics. Transmission electron microscopy performed on biopsy specimens from periprosthetic tissue revealed intracellular cocci in fibroblasts. All prostheses were removed without implanting a spacer, and antimicrobial agents were administered for 5.5-7 weeks. Reimplantation of the prosthesis was performed for 4 patients. Follow-ups were uneventful in all 5 cases.
  
  
  CONCLUSIONS
  In the case of a poor response to adequate antimicrobial and surgical treatment in implant-associated staphylococcal infections, small colony variants should be considered and actively sought. In our case series, a 2-stage exchange without implantation of a spacer combined with antimicrobial therapy for an implant-free interval of 6-8 weeks was associated with successful outcome, with a mean follow-up of 24 months.
authors.affiliation: Unit of Infectious Diseases, Basel University Medical Clinic Liestal, Liestal, CH-4410, Switzerland. sendi-pa@magnet.ch
authors.forename: Parham
authors.initials: P
authors.lastname: Sendi
authors.forename: Markus
authors.initials: M
authors.lastname: Rohrbach
authors.forename: Peter
authors.initials: P
authors.lastname: Graber
authors.forename: Reno
authors.initials: R
authors.lastname: Frei
authors.forename: Peter E
authors.initials: PE
authors.lastname: Ochsner
authors.forename: Werner
authors.initials: W
authors.lastname: Zimmerli
mesh_terms: D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects*; D001426:Bacterial Proteins / Q000235:genetics; D002985:Clinical Protocols; D020878:Device Removal; D004352:Drug Resistance, Microbial; D006801:Humans; D008297:Male; D008826:Microbial Sensitivity Tests; D046529:Microscopy, Electron, Transmission / Q000379:methods; D008875:Middle Aged; D010641:Phenotype; D016459:Prosthesis-Related Infections / Q000188:drug therapy / Q000382:microbiology*; D013211:Staphylococcus aureus / Q000302:isolation & purification
chemical_list: D000900:Anti-Bacterial Agents; D001426:Bacterial Proteins; C096686:FemA protein, Bacteria