Culture-directed Antibiotics Research Articles

Mucosal Microbiome Disruption in Acute Laryngeal Injury Following Intubation.

The objective of this study was to characterize mucosal microbial shifts in patients with acute laryngeal injury (ALgI) after intubation. This cross-sectional study included 20 patients with ALgI who underwent early endoscopic intervention with tissue culture, 20 patients with idiopathic subglottic stenosis (iSGS) who underwent tissue culture during the routine endoscopic intervention, and 3 control patients who underwent mucosal swab culture. 70% of the ALgI patients had a positive culture compared to 5% of the iSGS patients and none of the controls. The most identified microbes isolated from ALgI patients included Staphylococcus species in 30% and Streptococcus species in 25%. The high rate of pathologic bacterial infiltration into postintubation laryngeal wounds supports efforts to reduce bacterial colonization of endotracheal tubes and highlights the role of culture-directed antibiotic therapy as a part of early intervention to improve outcomes for patients with ALgI.

Empirical Antibiotic Therapy in Diabetic Foot Ulcer Infection Increases Hospitalization.

We evaluated the outcomes associated with initial antibiotic management strategies for infected diabetic foot ulcers (DFUs) diagnosed in an outpatient multidisciplinary center. Consecutive outpatient individuals with infected DFUs, stratified according to Infectious Diseases Society of America infection severity, were followed for 1 year from the initial antibiotic administration to treat acute infection. The main outcomes were hospitalization rates for a diabetes-related foot complication within 30 days of diagnosis and requiring an amputation or death during follow-up. Outcomes were analyzed by regression analysis, accounting for demographics, clinical characteristics, and antibiotic therapy. Among 147 outpatients with infected DFUs, 116 were included. Infections were categorized as mild (68%), moderate (26%), and severe (6%). Empirical antibiotics (not culture-guided) were prescribed as initial treatment in 39 individuals, while 77 received culture-based antibiotics. There were no differences in demographic or clinical characteristics between the antibiotic administration groups, except for a higher body mass index and prevalence of chronic kidney disease in the empirical cohort. Forty-two infected DFU patients required hospitalization within 30 days of diagnosis for the same reason. The relative risk for hospitalizations was 1.87 greater in those with mild infections when treated with empirical antibiotics compared with culture-directed antibiotics. There were no differences in amputations and/or death at 1 year follow-up. These data support obtaining tissue culture to guide antibiotic therapy, regardless of DFU infection severity, to decrease hospitalizations.

Bacteriological Profile and Drug Susceptibility in Mucosal type Chronic Suppurative Otitis Media.

In Chronic Suppurative Otitis Media, mucosal type, most common organisms are Pseudomonas aeruginosa and Proteus species (P. mirabilis and P. vulgaris). It is important to prescribe culture-directed antibiotics to prevent resistance. This study was conducted to determine the bacteriological profile and drug susceptibility in patient with chronic suppurative otitis media. This is a hospital-based descriptive study done at Gandaki Medical College, Pokhara, Nepal from July 2019 to June 2020. Under aseptic condition, the swab specimens were obtained from patients with history of ear discharge of >12 weeks duration and findings central perforation of the tympanic membrane. The sample was labeled and immediately transferred to the microbiology lab for culture/sensitivity test according to the guidelines of the Clinical and Laboratory Standards Institute. Out of total 127 patients, 48 (37.8%) were male and 79 (62.2%) were female. One hundred and seven samples (84.3%) had positive culture while 20 samples (15.7%) had no growth. Staphylococcus aureus (43%), was the most common isolate followed by Pseudomonas aeruginosa (23.4%), Proteus mirabilis (9.3%), and Escherichia coli (8.4%). All the organisms isolated were 100% sensitive to imipenem followed by 96.2% sensitive to gentamicin and 95.3% to amikacin. Staphylococcus aureus (43%) was the most predominant isolate followed by Pseudomonas aeruginosa (23.4%), Proteus mirabilis (9.3%), and Escherichia coli (8.4%). Imipenem was the most sensitive antibiotic (100%) followed by gentamicin (96.2%), amikacin (95.3%), and ofloxacin (88.78%).

508-P: Association between Initial Outpatient Diabetic Foot Ulcers Infection Management Strategy and Hospitalization

The objective was to evaluate the impact of the initial management strategies for DFU infections diagnosed at an outpatient multidisciplinary center. In 2019, people with newly diagnosed DFU infection were followed for duration of therapy to determine hospitalization rates within 30 days of diagnosis. Consecutive patients were stratified according to Infectious Disease Society of America infection severity. Demographic, socioeconomic, and antibiotic data was recorded. Among 147 persons treated for DFU infection, 59% infections were mild, while 30% and 4% were moderate and severe, respectively. Empiric antibiotics, consisting of either a cephalosporin or penicillin (76%) were prescribed for initial treatment in 116 individuals, and 66% (n=77) of these had tissue cultures preceding the treatment. Despite initial management of outpatient infection, 42% of the entire cohort required hospitalization within 30 days of diagnosis; 50%, 38%, and 12% hospitalizations were mild, moderate, and severe infections, respectively. The percentage of hospitalizations which occurred in mild infection treated with only empiric antibiotic (58%) was 1.5x greater than culture-directed antibiotic therapy (34%) despite similar empiric antibiosis. High rates of hospitalizations occurred in moderate (49%) and severe (100%) DFU infection. Overall, there was a negative association (r = -0.50, p<0.05) between implementation of culture-directed antibiotic strategy and hospitalization, and increased hospitalizations with applying empiric therapy for mild DFU infection. These data strongly support the practice to obtain tissue culture regardless of DFU infection severity to guide further treatment, as it is negatively associated with hospitalization rates. It is therefore essential to ensure foot infection treatment involves culture-directed antibiotic therapy and is applied uniformly across infection severity. Disclosure B.M.Schmidt: None. D.G.Armstrong: Research Support; Medaxis LLC. R.Busui: Board Member; American Diabetes Association, Consultant; Averitas Pharma, Inc., Lexicon Pharmaceuticals, Inc., Nevro Corp., Novo Nordisk, Roche Diagnostics, Procter & Gamble, Research Support; Novo Nordisk, Medtronic, National Institutes of Health. Funding National Institute of Diabetes and Digestive and Kidney Diseases (1K23DK131261-01A1)

Bleach-Induced Chemical Sinusitis and Orbital Cellulitis Following Root Canal Treatment

The authors describe an unusual case of chemical sinusitis and orbital cellulitis secondary to a sodium hypochlorite accident in a patient who had just undergone root canal treatment. The patient presented with acute, progressive symptoms of unilateral maxillary sinusitis, facial cellulitis and orbital cellulitis which began hours after root canal treatment on the ipsilateral side. He was admitted to hospital under the care of the Otorhinolaryngology team and reviewed regularly by the Ophthalmologists. He underwent Endoscopic Sinus Surgery during his hospital stay. The intraoperative findings revealed necrotic sinus mucosa and slough within the involved maxillary sinus, which were suggestive of chemical burn injury induced by the highly alkaline sodium hypochlorite solution used during root canal treatment. He was treated postoperatively with regular nasal toilet, culture-directed antibiotics and topical ocular pressure-lowering eyedrops. He displayed a slow recovery with eventually no orbital sequelae, but experienced persistent cheek numbness three months post-injury. Severe chemical sinusitis with orbital cellulitis secondary to sodium hypochlorite accident is a rare complication of root canal treatment, with potentially severe consequences. It can present with symptoms similar to complicated acute bacterial sinusitis. Otorhinolaryngologists and dental surgeons should maintain a high index of suspicion when managing a patient post-root canal treatment with symptoms of unilateral sinusitis, facial cellulitis, orbital cellulitis and even airway compromise. This would allow prompt intervention before sight or life-threatening complications set in.

Saving the Exposed Deep Brain Stimulation Implant: A Comprehensive Review of Implant Extrusion and Reconstructive Options

Deep brain stimulation (DBS) for the treatment of Parkinson disease is susceptible to complications, such as hardware extrusion, most commonly at the scalp and chest. The authors describe their experience with the management of hardware extrusion and reconstruction with one of the largest single-institution experience and suggest an evidence-based treatment algorithm for the management of such cases. A retrospective review of hospital records was performed to identify patients who underwent DBS-related surgery and reconstruction from January 2015 to April 2020. Management of these patients involved culture-directed antibiotics, local wound debridement, various forms of reconstruction, and hardware removal when indicated. Ninety-four patients with 131 DBS-related procedures were included. Twelve patients (12.8%) had hardware extrusion, of which 6 occurred primarily at the scalp and 6 occurred primarily at the chest. Primary closure of scalp wounds (odds ratio, 0.05 [0.004-0.71], P = 0.035) was negatively associated with treatment success. The type of reconstruction of chest wounds did not affect its success ( P = 0.58); however, none of them involved a new surgical bed, such as contralateral or hypochondrial placement. Hardware extrusion is a significant complication of DBS-related surgery. Management of extrusion at the scalp should involve the use of tension-free, well-vascularized locoregional flaps as opposed to primary closure. Implantable pulse generator extrusions at the chest can be managed with both primary closure and repositioning in a new surgical bed. Extruded DBS implants may be salvaged with appropriate reconstructive considerations, and the authors suggest an evidence-based treatment algorithm.

One Size Does Not Fit All: Variability in Urinary Symptoms and Microbial Communities

The discovery of the urinary microbiome prompted researchers to begin characterizing microbiota associated with various health and disease states; however, the etiology of bladder infections, the most common urinary tract infection (UTI), is still simplistically attributed to the invasion of a uropathogen, mainly Escherichia coli, without regard for the resident microbial community. In addition, the clinical variability of UTI symptoms remains poorly understood. Very little research has been done to investigate the role of baseline microbial communities in development and resolution of UTI symptoms. The goal of this study was to identify associations between urinary microbiota and lower urinary tract symptoms profiles in adult women with UTI symptoms. This is a secondary analysis of a previously published IRB-approved study that included 225 women who reported having acute UTI symptoms, submitted catheterized urine specimens for analysis by an enhanced urine culture method and were assessed for symptom resolution 7-10 days after receiving culture-directed antibiotic treatment. In this UTI population, we identified six distinct symptom profiles, termed symptotypes, that were characterized by varying severity and degree of bother of certain lower urinary tract symptoms. These symptotypes were not associated with urotype or the presence of specific microbes. In participants with pain on presentation, the presence of non-E. coli and non-uropathogens was associated with persistence of symptoms at follow up; however, this was not true for those with E. coli urotype. These data suggest that the presence of E. coli may not account for the underlying cause of typical UTI symptoms; instead, co-existence of a uropathogen in the context of the existing urinary microbiota and the host may be responsible for these symptom profiles.

Outcomes with culture-directed antibiotics following microvascular free tissue reconstruction for osteonecrosis of the jaw

ObjectivesRadiation (ORNJ) and bisphosphonate-related (BRONJ) osteonecrosis of the jaw represent challenging entities to treat, with many patients requiring segmental resection and reconstruction with microvascular free tissue transfer (MFTT) in the setting of failed conservative therapy. Microvascular reconstruction is associated with higher post-operative complication rates when performed for advanced osteonecrosis versus oncologic defects. We hypothesize that basing antibiotic therapy on cultures obtained from the healthy bone marrow following resection during MFTT for ORNJ or BRONJ reduces rates of post-operative wound and surgical complications. Materials and methodsIn a retrospective cohort study spanning January 2016 to October 2018, 44 patients undergoing MFTT for ORNJ or BRONJ were identified. Patients were categorized into two cohorts: residual healthy marrow culture (n = 11; RHM), treated with antibiotics guided by cultures from healthy appearing mandible, and all others (n = 33; AO), treated with antibiotics guided by cultures from resected necrotic bone or purulent drainage. Patient, reconstruction, and outcome variables were compared via appropriate statistical tools. Results81.8% of the RHM cohort versus 24.2% of the AO cohort received long-term IV antibiotics. Rates of post-operative wound complications, including those necessitating operative management, were significantly lower in the RHM cohort. Rates of flap failure were similar across both groups. ConclusionAdministration of long-term IV antibiotics directed by native mandible cultures may decrease complication rates following MFTT for ORNJ or BRONJ by treating residual, smoldering infection. Concurrently, transplantation of well-vascularized free tissue likely improves antibiotic delivery. Findings are crucial for the development of a standardized treatment algorithm following microvascular reconstruction for advanced osteonecrosis.

Chronic rhinosinusitis: microbiology and treatment of acute exacerbations in patients after endoscopic surgery.

AbstractObjectiveAntibiotics are the mainstay of therapy for acute exacerbation of chronic rhinosinusitis. However, no treatment guidelines exist. Most clinicians follow the recommendations for acute bacterial rhinosinusitis, usually caused by Haemophilus influenzae, Streptococcus pneumoniae or Moraxella catarrhalis, and treat with amoxicillin or amoxicillin-clavulanate.MethodMedical data of 810 patients who had undergone endoscopic sinus surgery were analysed retrospectively. The results of bacterial cultures and treatment course were assessed in 152 patients who presented with acute exacerbation of chronic rhinosinusitis within 6 months of endoscopic sinus surgery.ResultsThe most common bacterial species present were Staphylococcus aureus (36 per cent), Pseudomonas aeruginosa (13 per cent) and Escherichia coli (11 per cent). Most of the isolates showed resistance or intermediate sensitivity to amoxicillin-clavulanate. Targeted antibiotic therapy was significantly more effective than empiric therapy (71 per cent versus 42 per cent). The most effective antibiotics were fluoroquinolones.ConclusionAcute exacerbation of chronic rhinosinusitis shows different microbiology than acute bacterial rhinosinusitis and requires a different therapeutic approach. It is optimally treated with culture-directed antibiotic therapy.

A RARE CASE OF RIGHT-SIDED TRICUSPID VALVE ENDOCARDITIS

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Right-sided endocarditis is a well-known condition that occurs predominantly in intravenous drug users (IVDA) and patients with cardiovascular implantable electronic devices, central venous lines, and congenital heart disease. The objective of this report is to describe a rare case of right-sided endocarditis that leads to cardiogenic shock and death. CASE PRESENTATION: A 29-year-old caucasian male with a history of polysubstance abuse, acromioclavicular joint septic arthritis, status epilepticus secondary to cerebral septic emboli, presented to the emergency department with complaints of shortness of breath, generalized weakness, and malaise. He was noted to have significant respiratory distress requiring initially noninvasive mechanical ventilation, he was intubated due to worsening respiratory failure. Cardiovascular examination revealed a pansystolic murmur heard over the left parasternal border. Transthoracic echocardiogram showed severe tricuspid valve regurgitation and moderately dilated right ventricle with an ejection fraction of 63%. A transesophageal echocardiogram revealed severe 3+ to 4+ tricuspid valve regurgitation along with large vegetation on the anterior leaflet of the tricuspid valve measuring 2.2 cm x 0.8 cm. There is the involvement of the subvalvular apparatus with another large vegetation measuring 1.1 cm x 0.8 cm on the chordal apparatus (FIGURE 1). The patient was found to be in cardiogenic versus septic shock related to tricuspid valve recurrent infective endocarditis. Despite the patient being placed on intravenous antibiotics and two pressors he still continued to deteriorate. Discussion with the family decided to make the patient comfort-care. The patient ultimately expired. DISCUSSION: Right-sided infective endocarditis (RSIE) patients represent 5-10% of all infective endocarditis cases, making it a rare clinical entity. It is most commonly seen in patients with a history of IVDA; however, it is also seen in patients on dialysis, congenital heart disease, immunocompromised states patients, and patients who have an intracardiac device. The diagnosis of RSIE is often delayed due to its signs and symptoms relatively different than left-sided infective endocarditis which is the specific target of the modified duke's criteria. Common symptoms include cough, hemoptysis, dyspnea, chest pain, and persistent fever. The primary diagnostic modalities are echocardiography and positive blood cultures. The mainstay of medical treatment is antibiotics; however if refractory then surgery is indicated in cases of right-sided heart failure due to severe tricuspid regurgitation, persistent bacteremia, refractory to culture-directed antibiotics, and tricuspid valve vegetations greater than 20 mm in length. CONCLUSIONS: Clinicians should be aware of the variety of presentations a patient with suspected endocarditis could have as disease prognosis relies on a prompt diagnosis. REFERENCE #1: Narvaez Muñoz Adrian Fernando, Ibarra Vargas Daniela Albina. Right-Sided Infective Endocarditis, Infective Endocarditis, Peter Magnusson and Robin Razmi. IntechOpen. March 24th 2019 REFERENCE #2: Varona J., Guerra J. Tricuspid Valve Endocarditis in a Nonaddicted Patient Without Predisposing Myocardiopathy. Revista Española De Cardiología (English Edition) 2004;57(10):993–996. REFERENCE #3: Ye R., Zhao L., Wang C., Wu X., Yan H. Clinical characteristics of septic pulmonary embolism in adults: A systematic review. Respiratory Medicine. 2014;108(1):1–8. DISCLOSURES: No relevant relationships by Adeeb Alquthami, source=Web Response No relevant relationships by Nishad Barve, source=Web Response No relevant relationships by HANAD BASHIR, source=Web Response No relevant relationships by NICOLE LAO, source=Web Response No relevant relationships by Gauranga Mahalwar, source=Web Response

Role of antibiotic resistance in urinary tract infection management: a cost-effectiveness analysis

Urinary tract infections and recurrent urinary tract infections pose substantial burdens on patients and healthcare systems. Testing and treatment strategies are increasingly important in the age of antibiotic resistance and stewardship. This study aimed to evaluate the cost effectiveness of urinary tract infection testing and treatment strategies with a focus on antibiotic resistance. We designed a decision tree to model the following 4 strategies for managing urinary tract infections: (1) empirical antibiotics first, followed by culture-directed antibiotics if symptoms persist; (2) urine culture first, followed by culture-directed antibiotics; (3) urine culture at the same time as empirical antibiotics, followed by culture-directed antibiotics, if symptoms persist; and (4) symptomatic treatment first, followed by culture-directed antibiotics, if symptoms persist. To model both patient- and society-level concerns, we built 3 versions of this model with different outcome measures: quality-adjusted life-years, symptom-free days, and antibiotic courses given. Societal cost of antibiotic resistance was modeled for each course of antibiotics given. The probability of urinary tract infection and the level of antibiotic resistance were modeled from 0% to 100%. We also extended the model to account for patients requiring catheterization for urine specimen collection. In our model, the antibiotic resistance rate was based either on the local antibiotic resistance patterns for patients presenting with sporadic urinary tract infections or on rate of resistance from prior urine cultures for patients with recurrent urinary tract infections. With the base case assumption of 20% antibiotic resistance, urine culture at the same time as empirical antibiotics was the most cost-effective strategy and maximized symptom-free days. However, empirical antibiotics was the most cost-effective strategy when antibiotic resistance was below 6%, whereas symptomatic treatment was the most cost-effective strategy when antibiotic resistance was above 80%. To minimize antibiotic use, symptomatic treatment first was always the best strategy followed by urine culture first. Sensitivity analyses with other input parameters did not affect the cost-effectiveness results. When we extended the model to include an office visit for catheterized urine specimens, empirical antibiotics became the most cost-effective option. We developed models for urinary tract infection management strategies that can be interpreted for patients initially presenting with urinary tract infections or those with recurrent urinary tract infections. Our results suggest that, in most cases, urine culture at the same time as empirical antibiotics is the most cost-effective strategy and maximizes symptom-free days. Empirical antibiotics first should only be considered if the expected antibiotic resistance is very low. If antibiotic resistance is expected to be very high, symptomatic treatment is the best strategy and minimizes antibiotic use.

Hyperbaric oxygen for refractory osteomyelitis

Refractory osteomyelitis is defined as a chronic osteomyelitis that persists or recurs after appropriate interventions have been performed or where acute osteomyelitis has not responded to accepted management techniques [1]. To date, no randomized clinical trials examining the effects of hyperbaric oxygen (HBO2) therapy on refractory osteomyelitis exist, and the number of new osteomyelitis clinical trials conducted over the past decade has been limited. However, based on a comprehensive review of the scientific literature, the addition of HBO2 therapy to routine surgical and antibiotic treatment of previously refractory osteomyelitis appears to be both safe and ultimately improves infection resolution rates. In most cases, the best clinical results are obtained when HBO2 treatment is administered in conjunction with culture-directed antibiotics and initiated soon after clinically indicated surgical debridement. Where extensive surgical debridement or removal of fixation hardware is relatively contraindicated (e.g., cranial, spinal, sternal, or pediatric osteomyelitis), a trial of culture-directed antibiotics and HBO2 therapy prior to undertaking more than limited surgical interventions provides a reasonable prospect for osteomyelitis cure. HBO2 therapy is ordinarily delivered on a once daily basis, five-seven days per week, for 90–120 minutes using 2.0–3.0 atmospheres absolute (ATA) pressure. Where prompt clinical improvement is seen, the existing regimen of antibiotics and HBO2 therapy should be continued for approximately four to six weeks. Typically, 20–40 HBO2 sessions are required to achieve sustained therapeutic benefit. In contrast, if prompt clinical response is not noted or osteomyelitis recurs after this initial treatment period, then continuation of the current antibiotic and HBO2 treatment regimen is unlikely to be effective. Instead, clinical management strategies should be reassessed and additional surgical debridement and/or modification of antibiotic therapy considered. Subsequent reinstitution of HBO2 therapy will again help maximize the overall chances for treatment success in these persistently refractory patients.

Challenging the gold standard: methods of sampling for microbial culture in patients with chronic rhinosinusitis

PurposeChronic rhinosinusitis (CRS) is a highly prevalent multifactorial disorder. Culture-directed antibiotics are frequently prescribed to patients with CRS and the middle nasal meatus (MM) is traditionally believed to be a representative sampling site of the sinuses as a whole. The purpose of our study was to reevaluate the reliability of the MM as a sampling site in patients with CRS who suffer from impaired drainage from the sinuses to the MM.MethodsSwabs and tissue biopsies were collected from the MM, maxillary sinus and frontal sinus from 50 patients with CRS. The results of bacterial culture were compared between sampling methods and sites in relation to the patency of the sinus ostia.Results782 bacterial isolates were cultured from the samples. Concordant results between the MM and the sinus cavity were noted in 80% of patients for the maxillary sinus, but only 66% for the frontal sinus and 76% for the sinuses a whole. The differences were similarly prevalent in patients with open and occluded sinus ostia. Notably, swabs from all three sites provided representative information in 92% of patients and tissue biopsies did not provide additional information compared to multiple swabs.ConclusionThe traditional method of sampling from the middle meatus provides inadequate information in 24% of patients with CRS, which may result in inadequate antibiotic therapy and contribute to increasing antibiotic resistance. Additional sampling from the sinuses should be recommended whenever possible, while invasive sampling is not necessary.

Comparative study of culture, next-generation sequencing, and immunoassay for identification of pathogen in diabetic foot ulcer.

Treatment of deep musculoskeletal infection (MSKI) begins with accurate identification of the offending pathogen, surgical excision/debridement, and a course of culture-directed antibiotics. Despite this, the incidence of recurrent infection continues to rise. A major contributor to this is inaccurate or negative initial cultures. Accurate identification of the main pathogen is paramount to treatment success. This is especially important in treating diabetic foot infections (DFIs) with limb salvage efforts. This study seeks to utilize standard culture, next-generation sequencing (NGS), and immunoassay for newly synthesized antibodies (NSA) to Staphylococcus aureus and Streptococcus agalactiae for diagnosis. This is a level II prospective observational study approved by our IRB. Thirty patients > 18 years of age who presented with a DFI and underwent surgical debridement or amputation by a single academic orthopedic surgeon from October 2018 to September 2019 were enrolled. Intraoperative samples were obtained from the base of the wound and sent for culture, NGS, and a peripheral blood sample was obtained at the time of diagnosis. NGS and culture were highly correlated for S. aureus (κ = 0.86) and S. agalactiae (κ = 1.0), NSA immunoassay and culture demonstrated a fair correlation for S. aureus (κ = 0.18) and S. agalactiae (κ = 0.67), and NGS and NSA immunoassay demonstrated fair correlation for S. aureus (κ = 0.1667) and S. agalactiae (κ = 0.67). Our study demonstrates a high concordance between culture and NGS in identifying the dominant pathogen in DFU. NGS may be a useful adjunct in DFI diagnosis.

Pharmacokinetics of culture-directed antibiotics for the treatment of peritonitis in automated peritoneal dialysis: A systematic narrative review.

The objectives of this study were to provide a summary of the pharmacokinetic data of some intraperitoneal (IP) antibiotics that could be used for both empirical and culture-directed therapy, as per the ISPD recommendations, and examine factors to consider when using IP antibiotics for the management of automated peritoneal dialysis (APD)-associated peritonitis. A literature search of PubMed, EMBASE, Scopus, MEDLINE and Google Scholar for articles published between 1998 and 2020 was conducted. To be eligible, articles had to describe the use of antibiotics via the IP route in adult patients ≥18 years old on APD in the context of pharmacokinetic studies or case reports/series. Articles describing the use of IP antibiotics that had been recently reviewed (cefazolin, vancomycin, gentamicin and ceftazidime) or administered for non-APD-associated peritonitis were excluded. A total of 1119 articles were identified, of which 983 abstracts were screened. Seventy-three full-text articles were assessed for eligibility. Eight records were included in the final study. Three reports had pharmacokinetic data in patients on APD without peritonitis. Each of cefepime 15 mg/kg IP, meropenem 0.5 g IP and fosfomycin 4 g IP given in single doses achieved drug plasma concentrations above the minimum inhibitory concentration for treating the susceptible organisms. The remaining five records were case series or reports in patients on APD with peritonitis. While pharmacokinetic data support intermittent cefepime 15 mg/kg IP daily, only meropenem 0.5 g IP and fosfomycin 4 g IP are likely to be effective if given in APD exchanges with dwell times of 15 h. Higher doses may be required in APD with shorter dwell times. Information on therapeutic efficacy was derived from case reports/series in individual patients and without therapeutic drug monitoring. Until more pharmacokinetic data are available on these antibiotics, it would be prudent to shift patients who develop peritonitis on APD to continuous ambulatory peritoneal dialysis, where pharmacokinetic information is more readily available.

One-stage revision is as effective as two-stage revision for chronic culture-negative periprosthetic joint infection after total hip and knee arthroplasty.

Removal of infected components and culture-directed antibiotics are important for the successful treatment of chronic periprosthetic joint infection (PJI). However, as many as 27% of chronic PJI patients yield negative culture results. Although culture negativity has been thought of as a contraindication to one-stage revision, data supporting this assertion are limited. The aim of our study was to report on the clinical outcomes for one-stage and two-stage exchange arthroplasty performed in patients with chronic culture-negative PJI. A total of 105 consecutive patients who underwent revision arthroplasty for chronic culture-negative PJI were retrospectively evaluated. One-stage revision arthroplasty was performed in 30 patients, while 75 patients underwent two-stage exchange, with a minimum of one year's follow-up. Reinfection, re-revision for septic and aseptic reasons, amputation, readmission, mortality, and length of stay were compared between the two treatment strategies. The patient demographic characteristics did not differ significantly between the groups. At a mean follow-up of 4.2 years, the treatment failure for reinfection for one-stage and two-stage revision was five (16.7%) and 15 patients (20.0%) (p = 0.691), and for septic re-revision was four (13.3%) and 11 patients (14.7%) (p = 0.863), respectively. No significant differences were observed between one-stage and two-stage revision for 30- 60- and 90-day readmissions (10.0% vs 8.0%; p = 0.714; 16.7% vs 9.3%; p = 0.325; and 26.7% vs 10.7%; p = 0.074), one-year mortality (3.3% vs 4.0%; p > 0.999), and amputation (3.3% vs 1.3%; p = 0.496). In this non-randomized study, one-stage revision arthroplasty demonstrated similar outcomes including reinfection, re-revision, and readmission rates for the treatment of chronic culture-negative PJI after TKA and THA compared to two-stage revision. This suggests culture negativity may not be a contraindication to one-stage revision arthroplasty for chronic culture-negative PJI in selected patients. Cite this article: Bone Joint J2021;103-B(3):515-521.

Arthroscopic assisted evacuation of a rare Brodie’s abscess in the femoral head of an adolescent girl – A case report

Brodie’s abscess is a form of subacute osteomyelitis. It is a diagnostic problem because such patients typically have mild local symptoms, few or no constitutional symptoms, and near-normal laboratory values. Though metaphyseal lesions were common in the proximal tibia and proximal femur, these lesions rarely affect the femoral head and neck. We report a case of a 16-year-old girl presenting with a rare Brodie’s abscess involving the femoral head that was treated using an arthroscopically assisted curettage of the lesion combined with culture-directed antibiotics. This unusual location would have increased the likelihood of incomplete excision of the diseased tissue and would have led to recurrence. To avoid these risks, we opted for arthroscopic curettage under fluoroscopic guidance using a lateral approach. By this improvised method, there was minimal resection of bone and we found this technique of evacuation safe, uncomplicated and minimally invasive which resulted in early recovery. Keywords: Arthroscopic debridement, Bone infection, Brodie’s abscess, Head of Femur, Hip joint, Subacute osteomyelitis.

Use of adjuvant hyperbaric oxygen therapy in a patient with traumatic inoculation of mucormycosis resulting in extremity amputation

A 64-year-old man with uncontrolled diabetes mellitus presented to the emergency department with worsening left lower extremity pain, hypotension, fever and altered mental status (figure 1). Eleven days prior, he...

Bacteriobilia in Hepato-Pancreato-Biliary Surgery: an Enemy or a Friend in Disguise?

Bacterial colonization of bile, known as bacteriobilia, is predisposed by biliary obstruction and/or biliary interventions. It can lead to an increase in postoperative infective complications through impairment of hepatic synthetic and immunological function and breakdown of intestinal mucosal barrier. However, various reports of bacteremia and increase in infective complications have not been translated into increased postoperative morbidity and mortality. Biliary interventions, including preoperative biliary drainage, have been shown to increase the rates of bacteriobilia, and in turn positive biliary cultures. However, the clinical implication of this biliary colonization and strategies to prevent postoperative infective complications are not well understood. Bacteriobilia may be difficult to prevent completely due to its occurrence from non-modifiable risk factors. However, sparing use of biliary interventions and early identification and treatment of bacteriobilia with culture-directed antibiotics can help prevent catastrophic postoperative infective complications. It is necessary for this culture-based practice to become part of a routine protocol, and every step must be taken to prevent bacteriobilia, and thereby avoid postoperative infective complications and optimize patient outcome.

Is There a Role for Suppressive Antibiotics in Patients With Periprosthetic Joint Infection (PJI) of Total Ankle Arthroplasty (TAA) Who Have Undergone Surgical Treatment?

Culture-directed antibiotic therapy is recommended for patients undergoing operative treatment of infected total ankle arthroplasty (TAA). Routine administration of suppressive antibiotics in patients with an ankle prosthesis in place is not warranted; however, in certain clinical circumstances, this may be of benefit. Consensus. Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).