Case Report: Kingella kingae causing prosthetic joint infection in an adult
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Introduction. Kingella kingae is a Gram-negative micro-organism that is rarely isolated as a pathogen in the adult population. Although widely reported to affect prosthetic heart valves, there have been no previously reported cases of K. kingae infecting prosthetic joints in adults.
Case Presentation. A 61-year-old patient with a history of rheumatoid arthritis presented with insidious onset of pain and swelling in her right shoulder, which had progressed to a discharging sinus. The patient had undergone a total shoulder replacement 11 years previously and had not developed any prior post-operative infections. She had been taking anti-TNF medication for 5 years prior to review for her rheumatoid disease. The patient underwent a two-stage revision replacement procedure, including implant removal, sinus excision and debridement. Deep tissue samples grew K. kingae post-operatively. The patient was commenced on intravenous ceftriaxone for 14 days, followed by a further 28 days of oral ciprofloxacin. A second-stage custom shoulder replacement was undertaken 10 months following the first stage and the patient made a good functional recovery.
Conclusion. The authors suggest that clinicians should be attuned to K. kingae as a potential pathogen for prosthetic joint infection, particularly in patients who are immunosuppressed. Two-stage revision procedures can ensure a favourable outcome and eradication of this pathogen from the joint. Beta lactams remain the principal antibiotic of choice.
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Reviewer comments have been satisfactorily addressed and sufficient methodology detail added to the revised submission.
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This is a study that would be of interest to the field and community. The reviewers have highlighted minor concerns with the work presented. Please ensure that you address their comments. Please provide more detail in the Methods section and ensure that software is consistently cited and its version and parameters included.
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Comments to Author
the case is written clearly with few suggestion: line 99: please rephrase the sentence to be more clear please italicized the name of microorganisms for example line 117 line 129 please add its before " growth" in the sentence "K. kingae is a particularly fastidious organism, and growth on" line 139-141 suggest to rephrase the sentence line 141 suggest use word "number" instead of "volumes" line 143 " use "are" instead of "is"
Please rate the quality of the presentation and structure of the manuscript
Good
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other …
Comments to Author
the case is written clearly with few suggestion: line 99: please rephrase the sentence to be more clear please italicized the name of microorganisms for example line 117 line 129 please add its before " growth" in the sentence "K. kingae is a particularly fastidious organism, and growth on" line 139-141 suggest to rephrase the sentence line 141 suggest use word "number" instead of "volumes" line 143 " use "are" instead of "is"
Please rate the quality of the presentation and structure of the manuscript
Good
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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Comments to Author
Thank you for the opportunity to review your case report which details a rare case of Kingella kingae in a prosthetic joint infection. Overall, this is well-structured and you have presented the case with good logic. However, this is lacking in microbiological detail in a few places which needs to be resolved. The final sentence of your conclusion is really key and I'm happy to see you have emphasised the importance of multidisciplinary collaboration in these cases. Points to be reviewed: - Species name needs to be italicised - There is no need to put K. kingae in brackets, as the general rule of thumb in microbiology is to state it once in full and then subsequently shortened. - Line 42: rephrase to "patients who are immune compromised" - Line 42: the authors might want to elaborate on what they …
Comments to Author
Thank you for the opportunity to review your case report which details a rare case of Kingella kingae in a prosthetic joint infection. Overall, this is well-structured and you have presented the case with good logic. However, this is lacking in microbiological detail in a few places which needs to be resolved. The final sentence of your conclusion is really key and I'm happy to see you have emphasised the importance of multidisciplinary collaboration in these cases. Points to be reviewed: - Species name needs to be italicised - There is no need to put K. kingae in brackets, as the general rule of thumb in microbiology is to state it once in full and then subsequently shortened. - Line 42: rephrase to "patients who are immune compromised" - Line 42: the authors might want to elaborate on what they mean by adherence to specific culture and isolation techniques - Line 48: "our clinic" - name the clinic, is this a surgical clinic/microbiology clinic? - Line 55: as this is a microbiology journal it might be worth describing what medialisation is - Figure 1: please use arrows to point out what you're describing - Line 62: were these swabs of the sinus and pus? Please clarify. - Line 71: What antibiotics had she been put on that were stopped? How long had she received them for and what route of administration? - Line 73: should read "at first stage" - Line 76&94: how many tissue samples? - Line 79: how many grams of gentamicin? - Line 81: why was fluclox chosen? - Line 82: this needs to be elaborated on extensively as this is a microbiology journal. How were the samples processed, were tissues homogenised? What medium - blood culture bottles/agar? How long was incubation, at what day did the cultures come up positive, what antimicrobial susceptibility tests were performed? How many tissue samples out of the total were positive? This is important information. - Line 96-97: why were these IV antibiotics chosen when the patient had IV ceftriaxone at first stage? - Line 97: it would be interesting to know if these samples were put up for prolonged incubation/additional culture medium based on the organism? - Figures 2 and 3 seem unnecessary for this journal. It would be interesting to see a Gram-stain of the isolate or what it looks like on agar plates? - Line 117: Staphylococcus aureus, not Staph aureus. Italicise. - Line 115: generalised sepsis? Surely just sepsis. - Line 116: what kind of culture? Tissue/swabs? Be more specific. - Line 140: Propionibacterium has been reclassified as Cutibacterium acnes, please change. - Line 152: 16S rRNA gene sequencing or PCR? - Line 155-157: this is a bit of a confusing sentence, please re-word - what do you mean? Expand. Also, have you looked at synovial biopsy vs fluid in PJI? In the cases you have reviewed have there been any cases of dry joints or do they all have sinuses? Was this patient offered radiologically-guided sample collection? - Line 157&164: when no organism has been identified at which point in the investigation? - Line 165: you mention synovial fluid culture again but this is not something that you have demonstrated here in this report, therefore I think this should be removed from the conclusion and just remain in the discussion.
Please rate the quality of the presentation and structure of the manuscript
Good
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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