Prolonged Systemic Antibiotic Research Articles

Systemic antibiotics are not required for successful two-stage revision hip arthroplasty.

The duration of systemic antibiotic treatment following first-stage revision surgery for periprosthetic joint infection (PJI) after total hip arthroplasty (THA) is contentious. Our philosophy is to perform an aggressive debridement, and to use a high local concentration of targeted antibiotics in cement beads and systemic prophylactic antibiotics alone. The aim of this study was to assess the success of this philosophy in the management of PJI of the hip using our two-stage protocol. The study involved a retrospective review of our prospectively collected database from which we identified all patients who underwent an intended two-stage revision for PJI of the hip. All patients had a diagnosis of PJI according to the major criteria of the Musculoskeletal Infection Society (MSIS) 2013, a minimum five-year follow-up, and were assessed using the MSIS working group outcome-reporting tool. The outcomes were grouped into 'successful' or 'unsuccessful'. A total of 299 two-stage revision THAs in 289 patients met the inclusion criteria, of whom 258 (86%) proceeded to second-stage surgery. Their mean age was 68.1 years (28 to 92). The median follow-up was 10.7 years (interquartile range (IQR) 6.3 to 15.0). A 91% success rate was seen in those patients who underwent reimplantation, decreasing to 86% when including those who did not proceed to reimplantation. The median duration of postoperative systemic antibiotics following the first stage was five days (IQR 5 to 9). There was no significant difference in outcome between those patients who were treated with antibiotics for ≤ 48 hours (p = 0.961) or ≤ five days (p = 0.376) compared with those who were treated with longer courses. Greater success rates were seen for Gram-positive PJIs (87%) than for Gram-negative (84%) and mixed-Gram PJIs (72%; p = 0.098). Aggressive surgical debridement with a high local concentration of targeted antibiotics at the time of first-stage revision surgery for PJI of the hip, without prolonged systemic antibiotics, provides a high rate of success, responsible antibiotic stewardship, and reduced hospital costs.

Diagnosis and treatment of chronic osteomyelitis based on nanomaterials.

Chronic osteomyelitis is a painful and serious disease caused by infected surgical prostheses or infected fractures. Traditional treatment includes surgical debridement followed by prolonged systemic antibiotics. However, excessive antibiotic use has been inducing rapid emergence of antibiotic-resistant bacteria worldwide. Additionally, it is difficult for antibiotics to penetrate internal sites of infection such as bone, thus limiting their efficacy. New approaches to treat chronic osteomyelitis remain a major challenge for orthopedic surgeons. Luckily, the development of nanotechnology has brought new antimicrobial options with high specificity to infection sites, offering a possible way to address these challenges. Substantial progress has been made in constructing antibacterial nanomaterials for treatment of chronic osteomyelitis. Here, we review some current strategies for treatment of chronic osteomyelitis and their underlying mechanisms.

Utility of prolonged prophylactic systemic antibiotics for wound drains in posterior spine surgery: a systematic review and meta-analysis.

Closed suction drains, often used after posterior spinal surgery, pose a potential risk of infection. To combat this risk, many surgeons opt for a prolonged prophylactic antibiotic regimen. Since 2015, several studies have shown that prolonged prophylactic systemic antibiotics (PPSA) for drains provides no additional benefit in reducing surgical site infection (SSI) rates. However, most of these studies lacked sufficient power to make reliable conclusions. To date, there has been no meta-analysis conducted to further investigate this issue. The aim of this study was to investigate whether a regimen of PPSA reduces the incidence of deep SSIs in adult patients with closed suction drains following posterior spinal surgeries. The protocol of the current systematic review was registered with PROSPERO. A systematic review of the literature in PubMed (Medline), Europe PMC, Embase, and Cochrane Review databases was conducted for all relevant literature with the keywords "spine," "antibiotics," "surgical site infection," "prophylaxis," and "drain." Retrospective and prospective studies investigating the effectiveness of PPSA in patients 18 years or older who underwent posterior cervical or thoracolumbar surgery and had postoperative wound drains were included. The primary outcome was the odds ratio for deep SSI based on the intervention (PPSA vs non-PPSA). The secondary outcomes were the rates of superficial and overall SSIs. From a total of 2558 titles identified from the search, 7 studies were chosen for final analysis. Three were randomized controlled trials (RCTs), and 4 were retrospective reviews. A total of 2446 patients were analyzed; 1149 received a PPSA regimen and 1297 received a non-PPSA regimen. Deep SSIs occurred in 45 patients (3.9%) and 46 patients (3.5%) in the PPSA and non-PPSA groups, respectively. The odds ratio for deep SSIs in the PPSA group compared with the non-PPSA group was 1.10 (95% CI 0.69-1.74), which was not statistically significant. Additionally, there were no differences in the rates of superficial and overall SSIs. There was a trend toward increased infections with multidrug-resistant bacteria (Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus) in the PPSA group; however, it was not possible to perform a durable statistical analysis because of the small number of reported organisms in the selected publications. This meta-analysis demonstrates that there is no reduction in rate of deep, superficial, and overall SSIs with prolonged prophylactic antibiotics after posterior spinal surgery involving the use of closed suction drains.

Physical Approaches to Prevent and Treat Bacterial Biofilm.

Prosthetic joint infection (PJI) presents several clinical challenges. This is in large part due to the formation of biofilm which can make infection eradication exceedingly difficult. Following an extensive literature search, this review surveys a variety of non-pharmacological methods of preventing and/or treating biofilm within the body and how they could be utilized in the treatment of PJI. Special attention has been paid to physical strategies such as heat, light, sound, and electromagnetic energy, and their uses in biofilm treatment. Though these methods are still under study, they offer a potential means to reduce the morbidity and financial burden related to multiple stage revisions and prolonged systemic antibiotic courses that make up the current gold standard in PJI treatment. Given that these options are still in the early stages of development and offer their own strengths and weaknesses, this review offers an assessment of each method, the progress made on each, and allows for comparison of methods with discussion of future challenges to their implementation in a clinical setting.

Complex Foot Infection Treated With Surgical Debridement and Antibiotic Loaded Calcium Sulfate—A Retrospective Cohort Study of 137 Cases

Complex foot infections involving bone and soft tissue in patients with co-morbidities such as diabetes and peripheral arterial disease (PAD) are a cause of significant hospital admission. They are associated with substantial economic costs to health services worldwide. Historically, severe foot infection has been treated with surgical debridement and prolonged courses of systemic antibiotics. Prolonged systemic antibiotic use increases the risk of drug side effects, antimicrobial resistance and Clostridium difficile infection. The purpose of this study was to investigate whether surgical debridement and implantation of antibiotic loaded calcium sulfate is effective in the resolution of foot infection and wound healing. A retrospective cohort study of 137 consecutive cases of osteomyelitis (127) or significant soft tissue infection (10) over 62 months from 02/2013 to 04/2018 was conducted following local ethical approval. All cases of infection were treated with surgical debridement and local antibiotic-loaded calcium sulfate. The primary outcomes of infection resolution, time to healing and duration of postoperative antibiotics were measured. In 137 cases, 88.3% of infections resolved. Infection was eradicated in 22 patients without postoperative systemic antibiotics. About 82.5% of wounds healed, with an average healing time of 11.3 weeks. Healing time was significantly increased for the co-morbidities of diabetes and PAD (p =< .05) and for those requiring prolonged systemic postoperative antibiotics. Conservative surgical debridement and implantation of local antibiotic impregnated calcium sulfate is safe and effective in managing complex foot infections. We advocate early surgical intervention before deeper tissue involvement to help preserve lower limb structure and function.

Implant-associated osteomyelitis: Development, characterisation, and application of a porcine model.

Implant-associated osteomyelitis: Development, characterisation, and application of a porcine model.

The Utility of Prolonged Prophylactic Systemic Antibiotics (PPSA) for Subfascial Drains After Degenerative Spine Surgery.

Retrospective cohort study. The aim of the current investigation was to evaluate the impact of prolonged prophylactic systemic antibiotics (PPSA) on the development of surgical site infection rate (SSIR) in degenerative spine surgery. Surgical drains are utilized postoperatively in posterior spine surgery to help minimize the risk of seroma formation. Prophylactic antibiotics while drains are in place are frequently used to reduce SSIR, though the practice remains controversial. We performed a single center, retrospective review of all patients that underwent posterior spinal surgery for cervical and lumbar degenerative pathology over a 3.5 year period (January 2016-July 2019). Patients underwent a traditional open posterior midline procedure with postoperative placement of a subfascial surgical drain. Antibiotics were administered for the duration of the drain (PPSA group) or for 24 hours postoperatively (non-PPSA group). The number of surgical site infections, organism, and Clostridium difficile infections was recorded. Three hundred thirty six patients were identified, 168 patients in the PPSA group and 168 in the non-PPSA groups. The overall SSIR was 5.36% (18/336). The SSIR for the non-PPSA and PPSA groups were 7.14% (12/168) and 3.57% (6/168), respectively (P = 0.146). While difference of SSIR between the groups was two-fold, it was not statistically significant. For the non-PPSA and PPSA groups, the SSIR for cervical (5.95% [5/84] vs. 2.38% [2/84], P = 0.443) and lumbar (8.33% [7/84], vs. 4.76% [4/84], P = 0.535) regions were not significantly different. C. difficile cases in the PPSA and non-PPSA groups were 1/168 and 0/168 respectively (P = 1.00). Our series demonstrate a two-fold reduction of SSI with implementation of PPSA regimen. This benefit was demonstrated separately for both cervical and lumbar regions. Randomized trials and increase in sample size are warranted to elucidate the significance of PPSA in posterior spinal surgery.Level of Evidence: 3.

Epidemiology, resistance characteristics, virulence determinants, and treatment outcomes of Staphylococcus aureus bone and joint infections: a one-year prospective study at a tertiary care hospital in India

ABSTRACT Purpose The study was aimed to explore the differences between the Staphylococcus aureus osteosynthesis-associated infection (OAI) and non-implant related infections (NIRI) in terms of epidemiology, resistance characteristics, virulence determinants, treatment, risk factors, and outcome. Methods A prospective study was conducted from 2018 through 2019. The phenotypic and genotypic characterization of S. aureus, risk factors, treatment, and outcome were compared. Results A total of 60 patients were included. 50% had OAIs (70%) (p = .045). Overall, MRSA (OR 0.69; p = .020) and old age (OR 0.95; p = 0.035) were the important risk factors. Implanted patients presented with the features of chronic osteomyelitis (93.3%, p = 0.01). NIRI cases composed of only 66.7% of OM, and 55% of them were acute. OAI isolates were more frequently luk gene positives (50%) than isolates from the NIRI group (33.3%). Patients with OAI by luk positive isolates significantly had prolonged hospital stay (p = 0.043; OR-0.96, CI-0.91–1.0). Most of the NIRIs (60%) managed with antibiotics, but frequent surgical intervention (OR 10.68; p = .024) with prolonged systemic antibiotics (OR 1.07; p = .029) helped all OAIs to recover. Patients without implants were recovered in a higher number (83.3%). Conclusion Our study highlighted that the differences exist between the OAI and NIRI, specifically in terms of clinical features, distribution of luk genes, treatment approach, and outcome. Risk factors for both types of infection remained the same.

Hyperbaric oxygen treatment: A complementary treatment modality of Modic changes?

Modic changes (MCs) have attracted great interest in recent years. The complex process of MC development and progression seems to involve interplay between mechanical, infective, inflammatory, and degenerative processes that cannot be clearly differentiated. Based on signal intensity on T1- and T2-weighted MRI scans, MCs can be divided three types: Type 1, Type 2, and Type 3. Predominantly Type 1 MCs are commonly associated with chronic low back pain that is unresponsive to classic treatment options. Infection with low-virulent anaerobic microorganisms, most commonly Propionibacterium acnes, has been implicated in MC development following a disc herniation when a tear enables bacteria to enter the disc. Recent studies in patients with chronic low back pain following a lumbar disc herniation associated with Type 1 MCs have reported promising results following prolonged systemic antibiotic treatment with amoxicillin-clavulanate. Hyperbaric oxygen therapy, as primary or adjuvant treatment in association combination with systemic antibiotics or anti-inflammatory therapy, could offer important advantages in treating patients with suspected low-virulent disc infections due to anaerobic microorganisms associated with Type 1 MCs. We believe that hyperbaric oxygenation could contribute to faster resolution of Type 1 MCs and associated pain through multiple effects—including direct antimicrobial effects through formation of reactive oxygen species (ROS), altering the favorable low oxygen tension milieu such that it becomes unfavorable for bacterial growth and survival, and anti-biofilm effects. Additionally, hyperbaric oxygenation could contribute to faster pain resolution via direct and indirect anti-inflammatory effects. As an adjuvant treatment administered in combination with systemic antibiotics, HBOT could increase the sensitivity of Propionibacterium acnes to antimicrobial drugs under hyperoxic conditions, resulting in faster MC resolution. Overall, the faster infection resolution, diminished bacterial load, and anti-inflammatory effects due to reduced cytokine expression and levels of infectious by-products could lead to faster pain resolution following HBOT, and a significant improvement of quality of life in these patients.

Clofazimine inhalation suspension for the aerosol treatment of pulmonary nontuberculous mycobacterial infections

BackgroundNontuberculous mycobacteria are recognized as a concern for cystic fibrosis (CF) patients due to increasing disease prevalence and the potential for detrimental effects on pulmonary function and mortality. Current standard of care involves prolonged systemic antibiotics, which often leads to severe side effects and poor treatment outcomes. In this study, we investigated the tolerability and efficacy of a novel inhaled therapeutic in various mouse models of NTM disease. MethodsWe developed clofazimine inhalation suspension (CIS), a novel formulation of clofazimine developed for inhaled administration. To determine the efficacy, minimum inhibitory concentrations were evaluated in vitro, and tolerability of CIS was determined in naïve mouse models over various durations. After establishing tolerability, CIS efficacy was tested in in vivo infection models of both Mycobacterium avium and M. abscessus. Lung and plasma clofazimine levels after chronic treatments were evaluated. ResultsClofazimine inhalation suspension demonstrated antimycobacterial activity in vitro, with MIC values between 0.125 and 2 μg/ml for M. avium complex and M. abscessus. Administration into naïve mice showed that CIS was well tolerated at doses up to 28 mg/kg over 28 consecutive treatments. In vivo, CIS was shown to significantly improve bacterial elimination from the lungs of both acute and chronic NTM-infected mouse models compared to negative controls and oral clofazimine administration. Clofazimine concentrations in lung tissue were approximately four times higher than the concentrations achieved by oral dosing. ConclusionClofazimine inhalation suspension is a well tolerated and effective novel therapeutic candidate for the treatment of NTM infections in mouse models.

Recommendations for management of infected aortic pathology based on current evidence

The management of infection involving the abdominal aorta requires clinical decisions based on patient factors and the nature of the infectious process. Any infection occurring after endovascular aortic aneurysm repair or open aortic replacement grafting should be treated promptly with appropriate systemic antibiotic therapy. Once a vascular prosthesis becomes infected, surgical treatment is necessary. There should be a low threshold for graft excision and extra-anatomic bypass in the presence of fistula or abscess cavity, when feasible entire graft should be excised. In selected patients, graft excision with in situ aorta reconstruction is an appropriate option using an autogenous femoral vein, cryopreserved allograft, or a prosthetic graft impregnated with antibiotic. The replaced in situ aortic graft should be covered with an omental pedicle. For primary aortic graft infections, endovascular treatment may act as a bridge to more definitive treatment; or, in the absence of gross retroperitoneal infections, endovascular grafting alone with prolonged systemic antibiotic therapy is a viable option, particularly in patients not fit for open surgical procedures.

In vitro testing of a first-in-class tri-alkylnorspermidine-biaryl antibiotic in an anti-biofilm silicone coating

Biofilm-related infection is among the worst complication to prosthetic joint replacement procedures; once established on the implant surface, biofilms show strong recalcitrance to clinical antibiotic therapy, frequently requiring costly revision procedures and prolonged systemic antibiotics for their removal. A well-designed active release coating might assist host immunity in clearing bacterial contaminants within the narrow perioperative window and ultimately prevent microbial colonization of the joint prosthesis. A first-in-class compound (CZ-01127) was tested as the active release agent in a silicone (Si) coating using an in vitro dynamic flow model of surgical site contamination and compared with analogous coatings containing clinical gold-standard antibiotics vancomycin and gentamicin; the CZ-01127 coating outperformed both vancomycin and gentamicin coatings and was the only to decrease the methicillin-resistant Staphylococcus aureus (MRSA) inocula below detectable limits for the first 3 days. The antimicrobial activity of CZ-01127, and for comparison vancomycin and gentamicin, were characterized against both planktonic and biofilm MRSA using the minimum inhibitory concentration (MIC) assay, serial passages, and serial dilution tests against established biofilms grown with a CBR 90 CDC biofilm reactor. Despite a similar MIC (1 µg/ml) and behavior in a 25-day serial passage analysis, CZ-01127 displayed much greater bactericidal activity against established biofilms and was the only to decrease biofilm colony forming units (CFUs) below detectable limits at the highest concentration tested (500 µg/ml). Coating release profiles were characterized using ATR-FTIR and displayed burst release kinetics within the decisive period of the perioperative window suggesting the silicon carrier is broadly useful for screening antibiotic compound for local delivery applications. Statement of SignificanceWith an aging population, an increasing number of people are undergoing total joint replacement procedures in which diseased joint tissues are replaced with permanent metallic implants. Some of these procedures are burdened by costly and debilitating infections. A promising approach to prevent infections is the use of an antimicrobial coating on the surface of the implant which releases antibiotics into the surgical site to prevent infection. In this study, we tested a new antibiotic compound formulated in a silicone coating. Data showed that this compound was more effective at killing pathogenic methicillin resistant Staphylococcus aureus (MRSA) bacteria than two clinical gold-standard antibiotics—vancomycin and gentamicin—and could be a promising agent for antimicrobial coating technologies.

Vancomycin elution, activity and impact on mechanical properties when added to orthopedic bone cement.

Infection incidence for total hip and knee arthroplasty (THA and TKA, respectively) is between 0.2% and 5% and results in approximately 100,000 device failures per year in the United States. Treatment requires prolonged systemic antibiotic therapy with additional surgical revisions. As a prophylactic measure against infection, antibiotics can be incorporated into bone cement during THA and TKA to provide drug administration at the implant site. Antibiotics in bone cement are only effective if they can elute out of the cement at a concentration that is active against common organisms. There is evidence that added antibiotics may affect the cement's mechanical properties, especially at higher dosages. The purposes of this investigation were to (i) determine the mechanical properties of a commercially available bone cement with the addition of vancomycin, (ii) determine the release characteristics of vancomycin added to bone cement, and (iii) evaluate eluted vancomycin efficacy at eliminating some of the most common causative orthopedic implant pathogens. Palacos bone cement was impregnated with incrementally larger clinically relevant weight percentages of vancomycin. Vancomycin is a treatment standard for invasive gram-positive infections, and Palacos cement is one of the most commonly used bone cements. After 21 days of curing in PBS, added masses of vancomycin greater than 0.5 g per 40.0 g cement packet decreased the cement's compressive yield strength to below ISO standard. The addition of vancomycin reduced the bone cement's mechanical properties in compression more than in bending. Vancomycin eluted from Palacos with a steady rise in eluted volume up to 8 days, after which non-therapeutic elution concentrations were observed up to a 60-day end point. The eluted concentration from samples with greater than 0.25 g vancomycin per Palacos packet was sufficient to eliminate a 103 colony forming unit per mL (CFU/mL) initial inoculum of S. aureus, including methicillin-resistant S. aureus (MRSA). However, none of the tested dosages were able to fully clear a 103 CFU/mL initial inoculum of a known high biofilm producing strain of S. epidermidis. When used for infection prophylaxis at the time of THA and TKA, the findings of this study do not support the addition of more than 0.5 g vancomycin to a 40 g packet of Palacos cement due to a reduction in compression yield strength below ISO standards. Vancomycin doses up to 0.5 g were shown to elute from the bone cement matrix and are effective at treating bacterial infections of 103 CFU/mL in bacterial strains of S. aureus, but may have limited effect against high-biofilm producing strains including S. epidermidis.

Discontinuation of Postoperative Prophylactic Antibiotics After Noninstrumented Spinal Surgery: Results of a Quality Improvement Project.

Numerous medical society guidelines recommend discontinuation of antibiotics at a maximum of 24 hours after noninstrumented spinal surgery, even when a drain is left in place. As a result of these recommendations, our institution's Neurosurgery Quality Improvement Committee decided to stop administering prolonged prophylactic systemic antibiotics (PPSAs) to patients with drains after noninstrumented spinal surgery. We retrospectively reviewed data for patients who had noninstrumented spinal surgery performed by a neurosurgeon at our institution between December 2012 and July 2014 (PPSA period) and December 2014 and July 2016 (non-PPSA period) and had a drain left in place postoperatively. In the PPSA period, patients received antibiotics until drain removal. In the non-PPSA period, patients received antibiotics for a maximum of 24 hours. We identified 58 patients in the PPSA period and 55 in the non-PPSA period. Discontinuation of PPSAs resulted in a nonsignificant increase in the frequency of surgical site infections (SSIs; 0% in the PPSA period vs 4% in the non-PPSA period; P = .24). After discontinuing PPSAs for patients with noninstrumented spinal procedures, as is recommended for quality improvement, we saw a nonsignificant increase in our rate of SSIs. Further monitoring of this population is warranted.

Oral-Only Linezolid-Rifampin Is Highly Effective Compared with Other Antibiotics for Periprosthetic Joint Infection: Study of a Mouse Model.

Background:The medical treatment of periprosthetic joint infection (PJI) involves prolonged systemic antibiotic courses, often with suboptimal clinical outcomes including increased morbidity and health-care costs. Oral and intravenous monotherapies and combination antibiotic regimens were evaluated in a mouse model of methicillin-resistant Staphylococcus aureus (MRSA) PJI.Methods:Oral linezolid with or without oral rifampin, intravenous vancomycin with oral rifampin, intravenous daptomycin or ceftaroline with or without oral rifampin, oral doxycycline, or sham treatment were administered at human-exposure doses for 6 weeks in a mouse model of PJI. Bacterial burden was assessed by in vivo bioluminescent imaging and ex vivo counting of colony-forming units (CFUs), and reactive bone changes were evaluated with radiographs and micro-computed tomography (μCT) imaging.Results:Oral-only linezolid-rifampin and all intravenous antibiotic-rifampin combinations resulted in no recoverable bacteria and minimized reactive bone changes. Although oral linezolid was the most effective monotherapy, all oral and intravenous antibiotic monotherapies failed to clear infection or prevent reactive bone changes.Conclusions:Combination antibiotic-rifampin regimens, including oral-only linezolid-rifampin and the newer ceftaroline-rifampin combinations, were highly effective and more efficacious than monotherapies when used against a preclinical MRSA PJI.Clinical Relevance:This study provides important preclinical evidence to better optimize future antibiotic therapy against PJIs. In particular, the oral-only linezolid-rifampin option might reduce venous access complications and health-care costs.

Variations in Strategies to Prevent Ventriculostomy-Related Infections: A Practice Survey.

The ideal strategy to prevent infections in patients with external ventricular drains (EVDs) is unclear. We conducted a cross-sectional survey of members of the Neurocritical Care Society on infection prevention practices for patients with EVDs between April and July 2015. The survey was completed by 52 individuals (5% response rate). Catheter selection, use of prolonged prophylactic systemic antibiotics (PPSAs), cerebrospinal fluid (CSF) collection policies, location of EVD placement, and performance of routine EVD exchanges varied. Antibiotic-impregnated catheters (AICs) and conventional catheters (CCs) were used with similar frequency, but no respondents reported routine use of silver-impregnated catheters (SICs). The majority of respondents were either neutral or disagreed with the need for PPSA with all catheter types (CC: 75%, AIC: 85%, and SIC: 87%). Despite this, 55% of the respondents reported PPSAs were routinely administered to patients with EVDs at their institutions. The majority (80%) of the respondents reported CSF collection only on an as-needed basis. The EVD placement was restricted to the operating room at 27% of the respondents' institutions. Only 2 respondents (4%) reported that routine EVD exchanges were performed at their institution. Practice patterns demonstrate that institutions use varying strategies to prevent ventriculostomy-related infections. Identification and further study of optimum care for these patients are essential to decrease the risk of complications and to aid development of practice standards.

Antibiotic prophylaxis for subdural and subgaleal drains

OBJECTIVE The authors sought to determine the effects of eliminating the use of prolonged prophylactic systemic antibiotics (PPSAs) in patients with subdural and subgaleal drains. METHODS Using a retrospective database, the authors collected data for patients over the age of 17 years who had undergone cranial surgery at their institution between December 2013 and July 2014 (PPSAs period) or between December 2014 and July 2015 (non-PPSAs period) and had subdural or subgaleal drains left in place postoperatively. RESULTS One hundred five patients in the PPSAs period and 80 in the non-PPSAs period were identified. The discontinuation of PPSAs did not result in an increase in the frequency of surgical site infection (SSI). The frequency of Clostridium difficile (CDI) and the growth of resistant bacteria were reduced in the non-PPSAs period in comparison with the PPSAs period. In the 8 months after the drain prophylaxis protocol was changed, $93,194.63 were saved in the costs of antibiotics and complications related to antibiotics. CONCLUSIONS After discontinuing PPSAs for patients with subdural or subgaleal drains at their institution, the authors did not observe an increase in the frequency of SSI. They did, however, note a decrease in the frequency of CDI and the growth of resistant organisms. It appears that not only can patients in this population do without PPSAs, but also that complications are avoided when antibiotic use is limited to 24 hours after surgery.

Risk of Resistant Organisms and Clostridium difficile with Prolonged Systemic Antibiotic Prophylaxis for Central Nervous System Devices.

Prolonged systemic antibiotic prophylaxis for central nervous system (CNS) devices may be associated with increased risk of antimicrobial resistance. The primary objective of this study was to determine the impact of prolonged CNS device antibiotic prophylaxis on the growth of resistant microorganisms and Clostridium difficile. This retrospective, observational, cohort study included patients admitted to intensive care units with traumatic brain injury or other neurocritical illness. Patients who received a CNS device and antibiotic prophylaxis for at least 72h were compared to patients with similar neurologic injuries who did not receive a CNS device. Study (n=116) and control (n=557) patients had mean APACHE II scores of 17.7±9.2 and 15.1±10.6 (p=0.004) with 53.4 and 24.6% receiving craniotomies (p<0.001), respectively. Mean CNS device duration was 9.9days, and 73% of patients received cefuroxime for prophylaxis. The study cohort had a higher absolute incidence of resistant organisms compared with the control cohort (15.5 vs 4.1%; odds ratio 1.93, 95% CI 0.93-4.03, p=0.078), though the study was underpowered to show statistical significance in multivariate analysis. C. difficile incidence was similar between groups (2.6 vs 2.0%; odds ratio 1.45, 95% CI 0.35-6.12, p=0.61). We found a higher incidence of resistant organisms in patients receiving prolonged antibiotic prophylaxis with a CNS device, but similar incidence of C. difficile compared to controls. Lack of data supporting prolonged antibiotic prophylaxis for CNS devices and the risk of nosocomial infections with resistant organisms encourage limiting prophylactic antibiotics to a short periprocedural course.

Sternoclavicular Joint Infection Treated with Debridement, Vancomycin-Loaded Calcium Sulfate, and Partial Pectoralis Muscle Flap: A Case Report.

We report the case of a forty-six-year-old man with a left sternoclavicular joint infection that was treated effectively with surgical debridement, the implantation of vancomycin-loaded calcium sulfate, a partial pectoralis major muscle flap, and two weeks of intravenous antibiotics. Sternoclavicular joint infection is a rare problem that has received little attention in the orthopaedic literature. The combined surgical procedure detailed here provided good soft-tissue coverage, avoided the potential toxic effect of prolonged systemic antibiotic therapy, and resulted in a good clinical outcome.

A Case Report on the Treatment of Metcillin-Resistant Staphylococcus Aureus (Mrsa) Infected Tibial Internal Fixation with Calcium

The formation of biofilm is one of the main contributing factors for unsuccessful treatment of osteomyelitis. It is formed through the bacterial adhesion to the fragments of dead bone. Poor perfusion or devascularization of an infected bone with changes in local pH further limits the diffusion of parental antibiotics. Calcium sulphate, a biocompatible and completely reabsorbable local carrier for antibiotics, has shown promising results in treating osteomyelitis. It is associated with less systemic effect and compliance issues when compared with conventional treatment of surgical debridement and prolonged systemic antibiotics.