Early Infection Rate Research Articles

FIRE Stones: impact of forced diuresis on the residual fragment rate after flexible ureteroscopy for destruction of kidney stones with laser—protocol for a randomized controlled two-parallel group multicenter trial with blinding evaluation

BackgroundLithiasis is a common and recurrent disease. Flexible ureteroscopy (fURS) is the cornerstone of laser treatment of kidney stones. Kidney stones destruction requires its laser pulverization into small fragments in order to remove them through the ureter or improve their spontaneous expulsion along the urinary tract. However, most of the time, all the micro-fragments and dust created cannot be extracted using our surgical tools and may stay intra-renally at the end of the procedure. Adjuvant treatments (such as forced diuresis, inversion or mechanical pressure) were previously described to improve the expulsion of stone fragments after extra-corporeal shock wave lithotripsy. Nevertheless, the impact of adjuvant treatment after fURS remains unclear and mainly theoretical.ObjectiveThe primary objective is to show that the injection of 40 mg of furosemide in slow intravenous during 10 min, after the procedure, increases the stone-free rate 3 months after a fURS for destruction of kidney stones with laser.Methods/designThe study will be a two-parallel group randomized, controlled, multicentric trial with a blinding evaluation. Nine French departments of urology will participate. Patients will be randomized in 2 groups: the experimental group (injection of 40 mg of furosemide at the end of the surgery) and a control one (usual care). Patients will be followed up for 3 months (± 2 weeks) after the surgery. Then, we will perform a low dose abdomino-pelvic CT scan. The primary outcome is the stone-free rate at 3 months. A centralized review of the images will be performed by two specialized radiologists, in a blind and crossed way to allow a homogenization of the results. The secondary outcomes will include the rate of early post-operative urinary tract infection (UTI), the evaluation of post-operative pain, and the safety of the use of furosemide in patients treated by fURS for renal stone laser destruction. As secondary objectives, it is also planned to look at the effect of the prescription of an alpha-blocker as usual treatment on stone-free rate and to assess the agreement between the imaging analysis of the urologist and the specialized radiologist.DiscussionLithiasis is a public health problem. It affects about 10% of the general population. This prevalence is increasing (multiplied by 3 in 40 years), partly due to changes in the population’s eating habits over the years. The lithiasis patient is a patient with a chronic disease requiring annual follow-up and who may suffer from multiple recurrences, with a recurrence rate at 5 years of 50%.Recurrences are partly due to residual fragments left in the kidneys at the end of the operation. Other risk factors for recurrence include dietary hygiene and the presence of an associated metabolic disease. The metabolic blood and urine tests recommended by the Association Française d’Urologie (AFU) can be used to manage these last two problems.As far as residual fragments are concerned, their presence leads to an early recurrence of stones because they form the bed for a new aggregation of crystals in the kidneys. Being able to reduce the rate of residual fragments in patients with the use of furosemide at the end of the intervention therefore seems essential in the management of recurrences in our patients. This will also improve our patients’ quality of life.Indeed, lithiasis disease leads to chronic pain associated with acute pain that motivates consultations to the emergency for specialized management. This study is the first to evaluate the impact of forced diuresis with the use of furosemide on the stone-free rate after a fURS for destruction of kidney stone with laser.Trial registrationClinicalTrials.gov Identifier: NCT05916963, first received: 22 June 2023.EU Clinical Trials Register EudraCT Number: 2022-502890-40-00.

Low Risk of Periprosthetic Joint Infection After Aseptic Revision Total Knee Arthroplasty With Intraosseous Vancomycin

BackgroundAseptic revisions are the most common reason for revision total knee arthroplasty (rTKA). Previous literature reports early periprosthetic joint infection (PJI) rates after aseptic rTKA to range from 3 to 9.4%. Intraosseous (IO) regional administration of vancomycin has previously been shown to produce high local tissue concentrations in primary and rTKA. However, no data exist on the effect of prophylactic IO vancomycin on early PJI rates in the setting of aseptic rTKA. The aim of this study was to determine the following: (1) what is the rate of early PJI during the first year after surgery in aseptic rTKA performed with IO vancomycin; and (2) how does this compare to previously published PJI rates after rTKA. MethodsA consecutive series of 117 cases were included in this study who underwent rTKA between January 2016 and March 2022 by 1 of 2 fellowship-trained adult reconstruction surgeons and received IO vancomycin at the time of surgery in addition to standard intravenous antibiotic prophylaxis. Rates of PJI at 3 months, 1 year, and the final follow-up were evaluated and compared to prior literature. ResultsFollow-up at 3 months was available for 116 of the 117 rTKAs, with 1 lost to follow-up. The rate of PJI was 0% at 3 months postoperatively. Follow-up at 1 year was obtained for 113 of the 117 rTKAs, and the PJI rate remained 0%. The rate of PJI at the final follow-up of ≥ 1 year was 0.88% (95% confidence interval: −0.84 to 2.61). Previous literature reports PJI rates in aseptic rTKA to range from 3 to 9.4%. ConclusionsDual prophylactic antibiotics with IO vancomycin in conjunction with intravenous cephalosporins or clindamycin were associated with a substantial reduction in early PJI compared to prior published literature. These data supplement the early evidence about the potential clinical benefits of IO vancomycin for infection prevention in high-risk cases. Level of EvidenceLevel III, therapeutic study.

In Vivo Effects of Porcine and Rabbit Antithymocyte Globulin in Patients with Severe Aplastic Anemia

Background: Severeaplastic anemia (SAA) is a bone marrow failure disorder mediated by T lymphocytes, resulting in severe deficiency of hematopoietic stem cells. Horse antithymocyte globulin (H-ATG) plus cyclosporin was the first-line therapy for SAA patients in the absence of an HLA-matched sibling 1. The inhibitory effect of Rabbit-ATG (R-ATG) on lymphocytes is more deeply than that of H-ATG, and the recovery of CD4 T cells is slower, resulting in poor efficacy in SAA patients 2. Porcine ATG (P-ATG) and R-ATG are two available immunosuppressive choices in China mainland, the first-line formulation of ATG remains unknown. Methods: From November 2020 through September 2022, we performed a prospective, multi-center, non-randomized trial comparing two ATG formulations. 15 patients received R-ATG therapy and 45 patients treated with P-ATG were collected by prospective registration (ChiCTR2200055696) in the Chinese Eastern Collaboration Group of Anemia (CECGA). The pharmacokinetics, dynamic changes of peripheral blood cells were evaluated. Hematologic responses were also evaluated at 3, 6 months after treatment. Results: In both P-ATG-treated and R-ATG-treated patients, ATG reached highest concentration 5 days after treatment (1268.4 ± 381.1 ug/ml and 641.2 ± 448.5 ug/ml for P-ATG and R-ATG, respectively), and gradually decreased. At week 2, week 3 and 1 month from the peak values when be assessed, the P-ATG concentration decreased by 70.3%, 81.7%, and 85.4%, while the R-ATG concentration decreased by 68.9%, 88.5%, and 92.2%, respectively. R-ATG showed more powerful effects in depleting peripheral blood lymphocytes than P-ATG, while P-ATG displayed rapid recovery of T cells (CD3 + T cells, CD4 + T cells and CD8 + T cells) (P-ATG vs R-ATG, CD3 + T cells: 30.18 ± 6.04% vs 0.49 ± 0.37%, p=0.0036; 60.58 ± 8.02% vs 7.16 ± 7.16%, p=0.0016; 77.83 ± 3.17% vs 59.67 ± 7.93%, p= 0.015 for day 3, week 1 and week 3, respectively; CD4 + T cells: 9.13 ± 2.20% vs 0.03 ± 0.02%, p=0.013, 24.49 ± 4.21% vs 1.75 ± 1.75%, p=0.0076; 38.49 ± 3.02% vs 17.62 ± 3.79%, p=0.0007 for day 3, week 1 and week 3, respectively; CD8 + T cells: 16.77 ± 4.15 vs 0.10 ± 0.067, p=0.015; 27.55 ± 3.56% vs 4.94 ± 4.94%, p=0.0036; 33.80 ± 2.19% vs 35.67 ± 6.20, p=0.72 for day 3, week 1 and week 3, respectively). There were lower number of neutrophils in patients treated with R-ATG than those treated with P-ATG during the first week after immunosuppressive therapy (P-ATG vs R-ATG, Day 3: 3.46 ± 0.49 vs 1.29 ± 0.56, p=0.02; Day 5: 3.73 ± 0.56 vs 1.12 ± 0.55, p=0.02). The overall response rates were comparable between P-ATG and R-ATG at third month and sixth month (60% vs 40%, p=0.24; 60% vs 60%, p=1). Early infection rates (within 1 month) showed no significant differences in two formulations (P-ATG vs R-ATG, 33.33% vs 46.67%, p=0.76). There were five deaths in patients treated with P-ATG and three deaths in R-ATG-treated patients (P-ATG vs R-ATG, 11.1% vs 20.0%, p=0.40). Conclusion: P-ATG and R-ATG showed different pharmacokinetics and effects on neutrophils, lymphocyte subsets, which may lead to diverse immunosuppression. These two kinds of globulins showed comparable overall response rate after treatment. Reference 1. Scheinberg P, Nunez O, Weinstein B, et al. Horse versus rabbit antithymocyte globulin in acquired aplastic anemia. N Engl J Med. 2011;365(5):430-438. 2. Feng X, Scheinberg P, Biancotto A, et al. In vivo effects of horse and rabbit antithymocyte globulin in patients with severe aplastic anemia. Haematologica. 2014;99(9):1433-1440.

Knee

The October 2023 Knee Roundup360 looks at: Cementless total knee arthroplasty is associated with more revisions within a year; Kinematically and mechanically aligned total knee arthroplasties: long-term follow-up; Aspirin thromboprophylaxis following primary total knee arthroplasty is associated with a lower rate of early periprosthetic joint infection compared with other agents; The impact of a revision arthroplasty network on patient outcomes; Re-revision knee arthroplasty in a tertiary centre: how does infection impact on outcomes?; Does the knee joint have its own microbiome?; Revision knee surgery provision in Scotland; Aspirin is a safe and effective thromboembolic prophylaxis after total knee arthroplasty: a systematic review and meta-analysis; Patellar resurfacing and kneeling ability after total knee arthroplasty: a systematic review.

Adverse events and efficacy of second-round CAR-T cell therapy in relapsed pediatric B-ALL.

Chimeric antigen receptor (CAR) T-cell therapy has transformed the treatment approach for pediatric patients suffering from relapsed/refractory B-cell acute lymphoblastic leukemia (B-ALL). However, there was a paucity of data on the challenges associated with second-round CAR-T therapy in this population. Medical records of nine pediatric patients who received second-round CAR-T therapy in a single center from June 2019 to May 2023 were analyzed. Throughout the course of the clinical trial, we evaluated adverse events including CRS, CRES, infections, hematologic toxicity, and organ injury, as well as CAR-T responses. Except for one patient who chose CART therapy due to testicular relapse, the remaining patients had indications for CAR-T therapy due to relapse with bone marrow alone or combined with other site. There were no difference between the transfusion dose of CART1 and CART2. No differences of incidence and grade of CRS was found between the first-round CAR-T therapy (CART1) and second-round CAR-T therapy (CART2). Additionally, we found that the incidence of CRES was higher for CART1(3/9,33.3%) than CART2(1/9,11.1%). Our findings revealed that there were no differences of IL-2, IL-4, IL-6, IL-10, IFN-γ, and TNF-α between CART1 and CART2, but the peak level of IL-17A was significantly higher in patients receiving CART1 compared to those receiving CART2 (p = .011). Early and late infection rates after CART1 were higher than CART2. Based on the dynamic changes of ANC, hemoglobin and platelet, ANC, and platelet were reduced obviously post CART. It seems that the incidences of severe thrombocytopenia and severe anemia were higher in the CART1 group compared to CART2. The MRD-negative CR rates for CART1 and CART2 are 100% and 44.4%, respectively (p = .029). All patients experienced events (relapse, chemotherapy, transplantation, or death) after receiving CART2, including one died, three discharged automatically, and the remaining five patients survived. Although the remission rate of CART2 is not as high as the CART1 due to the severity of the disease, its safety regarding CRS, CRES, infections, and organ injury is still excellent. Therefore, CART2 remains a viable option for treating pediatric relapsed B-ALL.

Comparison of normal saline and antiseptic solution effect on the early peristomal infection rates of patients with percutaneous endoscopic gastrostomy tubes: A randomized double-blind study.

This study's aim was to compare the efficacy of normal saline (NS) with that of antiseptic solution in early peristomal skin care after percutaneous endoscopic gastrostomy placement in terms of peristomal infection incidence. This was a randomized controlled double-blind study conducted at a university hospital between December 2019 and April 2021. All patients who underwent percutaneous endoscopic gastrostomy and met the inclusion and exclusion criteria were included in the study. The study population consisted of 64 patients randomized to group 1: NS (n = 31) and group 2: 0.1% polyhexamethylene biguanide and 0.1% betaine (PHMB-B; n = 33). Daily peristomal skin care was performed for 7 days, starting 24 h after insertion. Peristomal skin was evaluated by two blinded investigators before each dressing, and findings were recorded. Data analysis was performed with descriptive statistics; chi-square analysis; and exact, Shapiro-Wilk, Mann-Whitney U, and Cochran Q tests. There was no statistically significant difference between the groups in terms of peristomal infection rates (group 1: 12.9%, group 2: 9.07%; P > 0.05). Redness increased from day 4 in group 1 and day 5 in group 2, and exudate increased from day 5 in both groups. There is a statistical difference in the number of patients between the days when redness and exudate appear and increase. Both NS and PHMB-B solutions can be preferred in peristomal care. However, NS may be the first choice for early peristomal care that does not show signs of infection, because it is not irritating and allergic and is cost-effective.

Oral Health Screening for Risk Reduction for Early Periprosthetic Joint Infections of Hip and Knee Endoprostheses—Results of a Prospective Cohort Study

This prospective observational study had two aims: (I) to assess whether a preoperative dental screening before endoprosthesis (EP) implantation with need-based dental intervention would decrease the prevalence of periprosthetic joint infection (PJI) and (II) to evaluate whether instructed orthopedic surgeons would achieve similar results in oral screening as dentists. The preoperative oral health statuses of the patients, prior to EP insertion, were either evaluated by the patients’ general dentists (Ia) or, if the patient had not visited a general dentist, by an instructed orthopedic surgeon (Ib). Both the dentist and orthopedic surgeon used standardized risk estimation (low risk, moderate risk, and high risk) for an oral-health-related infectious complication after EP insertion, including a recommendation for further management of the patient. If required, a need-based dental rehabilitation was performed. In addition, retrospective data evaluation of a comparison group (II) was performed, which had not been screened orally preoperatively. A total of 777 patients (screening group (I): n = 402, of which 229 were screened by a dentist (Ia), 173 were screened by an orthopedic surgeon (Ib); comparison group (II): n = 375) were included. No general association between early infection rate and preoperative oral screening in general was found (1% PJI in screening group (I), 1.6% PJI in comparison group (II); p = 0.455). However, screening performance (dentist vs. orthopedic surgeon) had a significant impact on the prevalence of developed PJIs (p = 0.021). Thereby, 100% of observed infections in the screening group (I) occurred in the group with previous oral screening by an orthopedic surgeon (Ib). Furthermore, the C-reactive protein (CRP) value at discharge was significantly lower when general preoperative oral screening had been performed (group I vs. group II, p = 0.03). Only preoperative oral screening by a dentist had the potential to reduce oral-focus-associated EP infections; therefore, increased attention should be paid to the further promotion of interdisciplinary work between dentists and orthopedic surgeons. Dental screenings, using objectifiable criteria, as applied in this study, seem reasonable but require further validation in larger cohorts.

Early surgical site infections in patients undergoing orthopaedic oncologic resection following change in perioperative antibiotic selection: A pre-post intervention study

BackgroundAt our institution, cefepime and vancomycin (FEP/VAN) were historically used for perioperative antimicrobial prophylaxis in malignant musculoskeletal tumor patients; however, prophylaxis was modified to cefazolin and vancomycin (CFZ/VAN) on June 6th, 2015. Due to the paucity of guidance and data, this study was conducted to optimize perioperative antimicrobial prophylaxis and compare early surgical site infection (SSI) rates within this patient population. MethodsThis was a single center, pre-post intervention, non-inferiority study. We included orthopedic surgery patients with musculoskeletal tumors who underwent resection and endoprosthetic or allograft replacement and received perioperative antibiotic prophylaxis. Perioperative antimicrobial prophylaxis included FEP/VAN or CFZ/VAN followed by oral antibiotic prophylaxis. The main outcome was the incidence of early culture-proven SSIs occurring within 90 days post-procedure. Results75 patients were included in each arm (150 total). Early SSI rates were low (FEP/VAN: 2.67% vs CFZ/VAN: 5.4%, P = 0.68) with no statistically significant differences. There was not a single independent factor associated with an increased odds of early SSI. ConclusionThis study supports CFZ/VAN as appropriate perioperative antibiotic prophylaxis in this patient population. There was no statistically significant change in SSIs with the change from FEP/VAN. Hospital length of stay differed but did not contribute to increased early SSI development odds.

Preoperative Decolonization Appears to Reduce the Risk of Infection in High-Risk Groups Undergoing Total Hip Arthroplasty.

Periprosthetic infections represent a major challenge for doctors and patients. The aim of this study was therefore to determine whether the risk of infection can be positively influenced by preoperative decolonization of the skin and mucous membranes. In a retrospective analysis of 3082 patients who had undergone THA between 2014 and 2020, preoperative decolonization with octenidine dihydrochlorid was performed in the intervention group. In an interval of 30 days, soft tissue and prosthesis infections were detected, and an evaluation between the study groups was made by using a bilateral t-test regarding the presence of an early infection. The study groups were identical with regard to the ASA score, comorbidities, and risk factors. Patients treated preoperatively with the octenidine dihydrochloride protocol showed lower early infection rates. In the group of intermediate- and high-risk patients (ASA 3 and higher), there was generally a significantly increased risk. The risk of wound or joint infection within 30 days was 1.99% higher for patients with ASA 3 or higher than for patients with standard care (4.11% [13/316] vs. 2.02% [10/494]; p = 0.08, relative risk 2.03). Preoperative decolonization shows no effect on the risk of infection that increases with age, and a gender-specific effect could not be detected. Looking at the body mass index, it could be shown that sacropenia or obesity leads to increased infection rates. Preoperative decolonization led to lower infection rates in percentage terms, which, however, did not prove to be significant (BMI < 20 1.98% [5/252] vs. 1.31% [5/382], relative risk 1.43, BMI > 30 2.58% [5/194] vs. 1.20% [4/334], relative risk 2.15). In the spectrum of patients with diabetes, it could be shown that preoperative decolonization leads to a significantly lower risk of infection (infections without protocol 18.3% (15/82), infections with protocol 8.50% (13/153), relative risk 2.15, p = 0.04. Preoperative decolonization appears to show a benefit, especially for the high-risk groups, despite the fact that in this patient group there is a high potential for resulting complications.

Ballistic diaphyseal forearm fractures result in high incidence of neurovascular injury and compartment syndrome but have low rates of early infection: A single level I trauma center experience

IntroductionBallistic injuries to the upper extremity represent a small subset of injuries, and there is little data to provide guidance on management and outcomes. The purpose of this study is to assess the incidence of neurovascular injuries, compartment syndrome, and early postoperative infection, as well as patient and injury factors predictive of neurovascular injury following ballistic fractures of the forearm. Patients and methodsA retrospective review of operatively treated ballistic forearm fractures at a single level I trauma center between 2010 and 2022 was performed. Thirty-three patients with 36 forearm fractures were identified. Only diaphyseal injuries in patients greater than 18 years old were included. Medical and radiographic records were reviewed to identify pre-injury patient-specific factors, including age, sex, smoking status, and history of diabetes. Injury characteristics, including the type of firearm used, forearm fracture location, and any associated neurologic or vascular injury, as well as compartment syndrome, were collected and analyzed. Short-term outcomes such as post-operative infection and recovery of neurologic function were also collected and analyzed. ResultsThe median age was 27 years (range: 18–62), with a majority of male patients (78.8%, n = 26). 4 patients (12.1%) sustained high-energy injuries. 4 patients (12.1%) were found to have compartment syndrome pre-operatively or intra-operatively. 11 patients (33.3%) had nerve palsies postoperatively with 8 patients (24.2%) continuing to have nerve palsies at their final follow-up (mean follow-up= 149.9 +/- 187.2 days). The median length of stay was 4 days. There were no patients with infection at follow-up. ConclusionBallistic forearm fractures are complex injuries and can result in severe complications such as neurovascular injury and compartment syndrome. As such, a comprehensive evaluation and appropriate management of ballistic forearm fractures are essential to minimize the risk of severe complications and optimize patient outcomes. In our experience, when treated operatively, these injuries have a low rate of infection.

Aspirin Thromboprophylaxis Following Primary Total Knee Arthroplasty Is Associated With a Lower Rate of Early Prosthetic Joint Infection Compared With Other Agents

BackgroundPatients undergoing total knee arthroplasty (TKA) are at increased risk of venous thromboembolism (VTE). Aspirin has been shown to be effective at reducing rates of VTE. In select patients, more potent thromboprophylaxis is indicated, which has been associated with increased rates of bleeding and wound complications. This study aimed to evaluate the effect of thromboprophylaxis choice on the rates of early prosthetic joint infection (PJI) following TKA. MethodsA review of 11,547 primary TKA patients from 2013 to 2019 at a single academic orthopaedic hospital was conducted. The primary outcome measure was PJI within 90 days of surgery as measured by Musculoskeletal Infection Society criteria. There were 59 (0.5%) patients diagnosed with early PJI. Chi-square and Welch-2 sample t-tests were used to determine statistically significant relationships between thromboprophylaxis and demographic variables. Significance was set at P < .05. Multivariate logistic regression adjusted for age, body mass index, sex, and Charlson comorbidity index was performed to identify and control for independent risk factors for early PJI. ResultsThere was a statistically significant difference in the rates of early PJI between the aspirin and non-aspirin group (0.3 versus 0.8%, P < .001). Multivariate logistic regressions revealed that patients given aspirin thromboprophylaxis had significantly lower odds of PJI (odds ratios = 0.51, 95% confidence interval = 0.29-0.89, P = .019) compared to non-aspirin patients. ConclusionThe use of aspirin thromboprophylaxis following primary TKA is independently associated with a lower rate of early PJIs. Arthroplasty surgeons should consider aspirin as the gold standard thromboprophylaxis in all patients in which it is deemed medically appropriate and should carefully weigh the morbidity of PJI in patients when non-aspirin thromboprophylaxis is considered. Level of EvidenceRetrospective, Therapeutic Level III.

Increased Rate of Early Periprosthetic Joint Infection in Total Hip Arthroplasty With the Use of Alternatives to Cefazolin Despite Additional Gram-Negative Coverage.

We would like to thank the commentary authors for their interest in our research and appreciate the opportunity to provide clarification. The commenter states that “I am aware that more non-cefazolin (CEZ) + Expanded gram negative antibiotic prophylaxis (EGNAP) patients develop infection by CEZ-resistant organisms…”. However, this claim was not made in our data, and the organism profile did not support this claim. We investigated the organism profile in periprosthetic joint infection for both groups and did not find a statistically significant difference in rates of gram-negative infections in either group.

P8.114: Recurrence Rate of Early HCV Infection After Renal Transplantation Following Successful Treatment of Dialysis Patients With Direct Acting Antiviral Agents

Introduction: HCV recurrence after organ transplantation has dreadful complications. Excellent response of direct acting antiviral agents (DAAs) in transplant recipients has been reported in various studies. Although, sustained virological response is considered as the virological cure, but it requires patients to be further 3 months on dialysis before undergoing renal transplant.Thus, increasing risk of HCV re-infection and associated complications. We aim to determine HCV recurrence in renal transplant recipients (RTRs) who has achieved end of treatment response (ETR) before transplant. Methods and Materials: As per institutional protocol dialysis patients who failed to achieve rapid virological response (RVR) were treated with 6 months of DAAs. All patients who have achieved ETR were then referred for transplantation. Kidney transplant recipients who were treatment experience with DAAs and had a HCV PCR done 3 months after transplant was enrolled. Participant’s demographic and clinical data was documented and statistical analysis was performed by SPSS 20.0. Results: In total 40 transplant recipients were included, majority were males (81.1%) with mean age of 28.7 ± 9.4 years. All patients had received sofosbuvir, daclatasavir and ribavirin combination prior to transplant. Majority of patients received treatment for 3 months (70%). Only 5 % of study population did not achieved RVR while all patients achieved ETR. Two patients also had treatment experience with interferon. Post-transplant HCV PCR was conducted at mean duration of 8.3 ± 3.3 months. Laboratory parameters showed Total Bilirubin 3.6 ± 17.5 mg/d, Alanine transaminase 51.5 ± IU/L 80.2 and gamma glutamyl transferase of 133.9 ± 220 IU/L. Post renal transplant HCV recurrence was documented in 2 (5%) recipients. Conclusion: This is first study to document excellent response of DAAs in renal transplant recipients who has been referred early for transplant. Thus, dialysis patients can undergo transplant after achieving end of treatment response.

Pathogens and Shift of Resistance in Early Infections after Operative Fracture Fixation.

Background: Surgical site infections (SSIs) remain a challenge for the healthcare system. During the last 30 years, the literature has shown an increase of gram-negative bacterial strains in multiple infectious sites and that cephalosporins have replaced penicillin as the gold standard in peri-operative antibiotic prophylaxis. This study aims to examine the recent bacterial spectrum in orthopedic early SSIs and to compare it with a historical cohort. Patients and Methods: Patients in a level 1 trauma center with an SSI within six weeks after open fixation of a fracture were analyzed in two adjacent periods from 2007 to 2012 (data pool 1; DP1) and 2013 to 2017 (data pool 2; DP2), retrospectively. The detected microbiologic pathogens and the associated resistograms from both time periods were compared. Results: Six hundred eighty-one smear tests and respective pathogens from the wounds of 463 patients (mean age, 62.6 ± 20 years) with SSIs were analyzed. The following pathogens were found most frequent: Staphylococcus epidermidis (DP1, 20.6%; DP2, 26.3%), Staphylococcus aureus (DP1, 27.1%; DP2, 16.5%), Enterococcus faecalis (DP1, 13.7%; DP2, 11.1%), Bacillus sp. (DP1, 3.0%; DP2, 5.3%), Escherichia coli (DP1, 5.1%; DP2, 4.1%), Pseudomonas aeruginosa (DP1, 3.7%; DP2, 2.5%). In DP2, there were lower primary early infection rates with Staphylococcus aureus than in DP1 (p = 0.002). In DP2, Staphylococcus epidermidis showed an oxacillin resistance in 90.6% and an increased resistance (79.8%; p = 0.069) to several classes of antibiotic agents compared to DP1. Conclusions: No bacterial shift toward gram-negative species was observed in this investigation. However, Staphylococcus epidermidis showed an increased antibiotic resistance in the more recent patient cohort. The incidence of SSIs with Staphylococcus aureus decreased substantially.

Lung Transplantation in HIV Patients

<h3>Purpose</h3> Limited published data exist on outcomes related to lung transplantation (LTx) in human immunodeficiency virus (HIV)-infected individuals. <h3>Methods</h3> We conducted a multicenter retrospective study of LTx in HIV- infected patients and describe key transplant- and HIV-related outcomes. <h3>Results</h3> We identified 22 HIV-infected LTx recipients across 25 transplant centers from 2007 through 2021. At transplantation, mean age was 53 [46 - 59] years, 55% were male. Two (9%) patients had an history of previous opportunistic infection and AIDS status. Pretransplant CD4 T cell count was 514 [351 - 670] cell/mm3 and RNA viral load was negative in all patients and their values did not change significantly post operatively. Due to calcineurin inhibitor interactions, 3 (15%) patients required an antiretroviral regimen change before LTx. Main indications for LTx were pulmonary arterial hypertension in 7 (32%), fibrosis in 5 (23%) and cystic fibrosis in 3 (14%). LTx procedure was predominantly bilateral-lung transplantation (91%). Immunosupression was giving according to local protocols including induction in 7 (32%) patients. During first post-LTx year, acute cellular rejection, antibody-mediated rejection, and infections requiring hospitalization occurred in 7 (37%), 2 (11%) and 8 (40%), respectively. During the median [range] follow-up of 25 [0.1-172] months, 26% and 14% of patients developed chronic lung allograft dysfunction and malignancy, respectively. Posttransplant survival rates after 1, 3, and 5 years were 79%, 79%, and 79%, respectively. At last news evaluation, 59% of the patients were fully active and independent. <h3>Conclusion</h3> Apart from early infection rates, survival rates and post-operative outcome were similar to their HIV-uninfected LTx recipients. At last follow-up, more than half of the patients had near-normal functional status.

Impact of Pre-Transplant Immunosuppression in CT-ILD Recipients

<h3>Purpose</h3> The use of immunosuppressive biologic agents (BA) in CT-ILD patients has increased. These agents have long half-lives and a high infection risk leading to our hypothesis that these patients will have more infectious complications. This study compares early outcomes in patients who received pre-transplant traditional immunosuppression (MMF, AZA, hydroxychloroquine, cyclophosphamide) (TI), pre-transplant BA (anti-CD20, TNF blockers, IL-6 inhibitors, JAK inhibitors) or no immunosuppression (IS). <h3>Methods</h3> Patients transplanted for ILD between 2/2008-4/2021 were retrospectively divided into 3 groups (grp): (1) TI, (2) BA, and (3) none. Maintenance IS included a calcineurin inhibitor, MMF/AZA, and prednisone. Targeted induction therapy with basiliximab occurred in patients with acute kidney injury post-transplant. Variables examined included baseline characteristics, infection within 6 mo, time to infection, and 1-yr survival. <h3>Results</h3> 161 pts were included in the analysis. 45 received TI, 13 received BA, and 103 received neither. Grps were comparable in age and induction therapy, but more males were present in each grp (p=0.001). Incidence of infection within 6 mo was higher in the TI grp compared to no IS grp (71% vs 46%, p=0.004). Time to initial infection was shorter in the TI grp (86 vs 119 vs 121 d) when compared to the BA and no IS cohorts (p=0.016). There was no difference in length of initial hospital stay or 1-yr survival. <h3>Conclusion</h3> Our single-center experience demonstrates that the utilization of traditional therapeutic immunosuppressive agents when compared to BA or no IS to treat CT-ILD prior to transplantation results in a greater risk of early infection but does not impact survival. Transplantation of patients receiving newer BA does not appear to increase early infection rates, but this may be due to selection bias or low numbers in this analysis. Discontinuing TI well ahead of the transplant may have a protective effect in preventing early post-transplant infection.

Increased Rate of Early Periprosthetic Joint Infection in Total Hip Arthroplasty With the Use of Alternatives to Cefazolin Despite Additional Gram-Negative Coverage.

BackgroundPeriprosthetic joint infection (PJI) remains one of the most devastating complications following total joint arthroplasty. Appropriate prophylactic antimicrobial administration and antibiotic stewardship are major factors impacting the risk of PJI in total hip arthroplasty (THA). The purpose of our study was to evaluate whether cefazolin administration was superior to noncefazolin antibiotics in prevention of PJI after primary THA.Material and methodsA review of 9910 patients undergoing primary THA from 2013 to 2019 at a single institution was conducted. The primary outcome was PJI within 90 days of surgery. The Musculoskeletal Infection Society definition of PJI was used for this analysis. Groups were those receiving cefazolin + expanded gram-negative antimicrobial prophylaxis (EGNAP) and those receiving an alternative to cefazolin + EGNAP. Chi-square tests were conducted to determine statistical significance. Multivariate logistic regression was performed to eliminate confounders.Results9028 patients received cefazolin + EGNAP, and 882 patients received an alternative to cefazolin + EGNAP. PJI rate using the Musculoskeletal Infection Society criteria was 0.82% (81/9910). PJI rate in the cefazolin + EGNAP group was 0.75% (68/9028). In the group receiving an alternative to cefazolin + EGNAP, the PJI rate was 1.47% (13/882). This difference was statistically significant (P = .023). On multivariate analysis, the odds ratio for developing PJI when an alternative to cefazolin was used was 2.05 (P = .022). When comparing alternatives, there remained a statistically significant increased PJI rate when the alternative used was clindamycin (odds ratio 2.65, P = .007).ConclusionOur data demonstrate that in the presence of EGNAP in THA, there was a higher PJI rate when clindamycin was given as an alternative to cefazolin. The number of THA patients receiving alternatives to cefazolin must be minimized.Level of EvidenceIII, Retrospective Cohort Study.

American Indian Reservations and COVID-19: Correlates of Early Infection Rates in the Pandemic: Erratum.

American Indian Reservations and COVID-19: Correlates of Early Infection Rates in the Pandemic: Erratum.

Long-acting granulocyte colony-stimulating factor in primary prophylaxis of early infection in patients with newly diagnosed multiple myeloma

PurposeThis study sought to compare the efficacy of prophylactic long-acting and standard granulocyte colony-stimulating factor (G-CSF) on febrile neutropenia, early infections, and treatment delay in patients with newly diagnosed multiple myeloma (MM) receiving the therapeutic regimen of bortezomib, lenalidomide, and dexamethasone (VRd).MethodsA prospective study with 68 consecutive patients with MM was conducted in three regional hospitals. Participants were randomly treated with the VRd regimen in combination with prophylactic long-acting G-CSF (treatment group) or prophylactic standard G-CSF (control group). The primary endpoints were the incidence rates of febrile neutropenia, early infection, and treatment delays. The secondary endpoint was clinical outcomes.ResultsThirty-three patients were assigned to the treatment group, and thirty-five patients were assigned to the control group. The incidence of febrile neutropenia was 6.1% and 17.1% in the treatment and control groups, respectively (p = 0.297). However, the rates of early infection and treatment delay were markedly lower in the treatment group than in the control group (6.1% vs. 25.7% and 9.1% vs. 31.4%; p < 0.05). Notably, all early infections occurred during the first four cycles of VRd therapy, and the most common type of infection was pneumonia. No significant difference in clinical efficacy was found between the two groups. All participants achieved at least partial remission.ConclusionsProphylactic administration of domestic long-acting G-CSF markedly reduced the rates of early infection and treatment delay as compared with standard G-CSF in patients newly diagnosed with MM. Notably, all early infections occurred during the first four cycles of VRd therapy. As such, it seems appropriate to administer long-acting G-CSF with the aim of primary prophylaxis of early infection in the setting of newly diagnosed MM.

A REVIEW OF GROUP B STREPTOCOCCUS (GBS) VAGINAL COLONIZATION AND ASCENDING INTRAUTERINE INFECTION: INTERACTION BETWEEN HOST IMMUNE RESPONSES AND GBS VIRULENCE FACTORS

Vaginal colonization with Group B streptococcus (GBS) or Streptococcus agalactiae can potentially cause ascending intrauterine infection among pregnant women, and hence it is known as one of the risk factors for preterm delivery. Ascending intrauterine infection may also cause the transmission of GBS to the fetus in utero and the newborn during delivery, leading to the development of early onset of neonatal infection. GBS are β-hemolytic, gram-positive bacteria that are opportunistic commensal of the gastrointestinal and urogenital tract of approximately 18% of pregnant women globally. Intrapartum antibiotic prophylaxis (IAP) only reduces the rate of early onset neonatal infection, but not the late onset neonatal infection. Thus, the development of GBS vaccine is thought to be important to decrease the rate of preterm delivery and neonatal infections particularly in low-and-middle income countries where IAP program is not feasible. Vaccination can also be cost-effective for the healthcare system when executed together with IAP program. The aim of the current review is to summarize the mechanisms on how the GBS virulence factors interact with host immune components in the gestational tissues, leading to cervicovaginal colonization and ascending intrauterine infection. The elucidation of these mechanisms is essential for expediting the development of vaccines and novel therapeutic measures targeting these GBS virulence factors that will hamper the vaginal colonization, ascending intrauterine infection and conceptus tissue invasion by GBS. These strategies are crucial to potentially reduce the rate of preterm delivery and subsequent serious complications in the newborn.