Elsevier

Anaerobe

Volume 71, October 2021, 102412
Anaerobe

Review Article
Native joint infections caused by Parvimonas micra

https://doi.org/10.1016/j.anaerobe.2021.102412Get rights and content

Highlights

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    P. micra is a fastidious organism responsible for rare infections of native joints.

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    A history of oral disease places patients at higher risk of P. micra infection.

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    Subacute and chronic inflammatory states are risk factors for infection by P. micra.

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    Identifying P. micra has increased due to MALDI-TOF-MS.

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    Common treatments are penicillin, clindamycin, or metronidazole for up to 10 weeks.

Abstract

Parvimonas micra is an anaerobic, fastidious, gram positive organism commonly found in the oral cavity and gastrointestinal tract. It has been increasingly reported as the cause of septic arthritis of native joints, often times with delayed diagnosis leading to increased morbidity. Risk factors include immunosuppression, inflammation of the joint, and recent dental procedures or infections. It has been a historically difficult organism to culture. However, the development of and increasing use of matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF-MS) has led to increased identification of P. micra. Common antibiotic susceptibilities, as well as data regarding susceptibilities in specific situations, have been reported, but susceptibility testing is required in all cases. Common treatments include clindamycin, penicillin, and metronidazole for six to ten weeks.

Introduction

Parvimonas micra is an anaerobic, gram positive organism. It was formerly known as Peptostreptococcus micros and Micromonas micros and was re-classified to its current name in 2006 [1]. It is a normal inhabitant of the oral and gastrointestinal microbiota and is a well-known cause of periodontitis. Outside of the oral cavity, it has been identified on rare occasions as the source of spondylodiscitis, iliopsoas abscesses, vertebral osteomyelitis, endocarditis, and meningitis [[2], [3], [4], [5]]. It has also been implicated in prosthetic joint infections [8]. Notably, there has been an increasing number of case reports in the literature describing native joint infections due to P. micra [[2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14]]. Septic arthritis is a surgical emergency with potentially devastating consequences, and many of these cases had delays in diagnosis due to difficulty identifying P. micra, when earlier diagnosis may have altered the outcome. This review aims to summarize the seven known cases of native joint septic arthritis (six published and one from our institution) and the current knowledge surrounding native joint infections due to this organism, so that prompt diagnosis may lead to positive outcomes in future cases.

Section snippets

Septic arthritis

Septic arthritis commonly presents in the lower extremity with fever, mono-articular pain, erythema, and swelling usually as a result of direct intra-articular inoculation of an infectious microorganism, hematogenous seeding from a distant site, or contiguous spread from a local site [[21], [22], [23]]. Joints are particularly susceptible to infection in part, due to their highly vascular synovium which lacks a basement membrane and allows bacteria to easily seed and grow within the joint

Risk factors for Parvimonas micra infection

Dietvorst et al. in their case discussion, proposed that a state of chronic inflammation may contribute to increased susceptibility of native joints to septic arthritis [11], and this review supports that proposal. Four of the reported cases note pre-existing osteoarthritis, which results in a chronic state of inflammation inside the joint [16]. In addition to these four, two more had a history of minor trauma that may have led to a state of subacute inflammation and placing these patients at

Clinical presentation of joint infections caused by P. micra

While the classic presentation of septic arthritis is an extremely painful, erythematous, warm joint, the published clinical presentations of septic arthritis due to P. micra described have been more subtle [[2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14]]. The original presenting symptoms are often gradual and nonspecific. The patients reported all either had pre-existing osteoarthritis or multiple medical comorbidities, which unfortunately seems to have contributed to a

Diagnostic challenge of P. Micra

Accurate diagnosis and identification of anaerobic bacteria such as P. micra present a challenging task to both the clinician and to the microbiologist for a multitude of reasons. P. micra does not grow well on standard, nonselective media [33]. A selective media for P. micra has been described by Turng et al. [34]. In aerated sites like many areas of the oral cavity and skin, anaerobes co-exist with aerobes, making isolation for pure culture and identification difficult and at high risk for

Susceptibility

Murdoch et al. found P. micra to be most susceptible to penicillin, followed by metronidazole and clindamycin [15]. Additional studies have shown susceptibility to levofloxacin and amoxicillin-clavulanic acid [23]. Data regarding P. micra susceptibility to antibiotics can be found in Table 1 [15,23,[27], [28], [29], [30], [31], [32]]. These studies were cited as the basis for choosing an antibiotic treatment regimen without first obtaining antibiotic susceptibility results, citing universal

Treatment

To date, there is no current standard treatment algorithm for septic arthritis caused by P. micra. The proposed treatments found in The most commonly selected antibiotics include IV Penicillin G, clindamycin, ampicillin/sulbactam, and metronidazole. The duration of treatment has also varied, most often ranging from six weeks to ten weeks [10,[12], [13], [14]]. The reported duration and dosage of treatments can be found in the appendix of this review. It should be noted, however, that many case

Conclusion

Parvimonas micra is an anaerobic, fastidious, gram positive organism commonly found in the gastrointestinal tract. It has been recently reported as the cause of septic arthritis of native joints. There are risk factors, including immunosuppression, inflammation of the joint, and recent dental procedures or infections that should raise suspicion for underlying infection due to this pathogen. It has historically been difficult to identify, but the development and increasing use of MALDI-TOF-MS

Declaration of interests

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.

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