Radiological Signs Of Infection Research Articles

A clinical protocol for immediate dental implant placement in post-extraction-infected sites decontaminated with Er,Cr:YSGG laser.

Placement of dental implants into fresh extraction sockets offers some advantages, such as reduced treatment times and enhanced patient comfort. The Er,Cr:YSGG (Erbium, Chromium-doped: Yttrium, Scandium, Gallium, and Garnet) laser can significantly reduce bacterial concentration after the extraction of a compromised tooth. The aim of this article is to provide a clinical protocol for the management of implants placed in infected extraction sites decontaminated with Er,Cr:YSGG laser. A compromised tooth, which was an abutment for a fixed bridge, with clinical and radiological signs of infection was extracted. The infected site was treated and decontaminated with an Er,Cr:YSGG laser device (Biolase iPlus®) and two implants (Straumann®) were placed in the same surgery, in order to rehabilitate the edentulous area. The intervention was completed by tissue regeneration with biomaterials. Prosthetic rehabilitation after the surgical phase allowed us to provide correct function and satisfactory esthetics. In the follow-up visit, clinicians found good tissue healing and did not observe any complications, such as implant loss or peri-implantitis. The technique used in our study is repeatable and predictable, but patient selection is very important for this type of protocol as the presence of contraindications can lead to failure. The photoacoustic effect exerted by this type of laser has been proven to be effective against many pathogens. Several authors have previously demonstrated the effectiveness of this technique. Immediate implantation in infected sites decontaminated with Er,Cr:YSGG laser does not seem to contribute to an increased risk of failure; however, it is necessary to follow a certain set of protocols and procedures to prevent peri-implantitis and other complications.

Septic Tibial Shaft Non-Union Treated by One-Step Surgery Using a Custom-Made Intramedullary Antibiotic Cement-Coated Carbon Nail: Case Report, Focus on Surgical Technique and Brief Literature Review

Septic non-union (SNU) represents an insidious complication of open fractures. SNU is defined as a clinical and radiological evidence of cessation of fracture healing after 6-8 months of treatment, associated with persistence of clinical, laboratoristic and radiological signs of infection. The infection is mostly caused by bacteria and when it occurs at the bone fracture site, the healing process slows down and generally the treatment takes place in multiple phases. First a surgical debridement, often with the use of polymethylmethacrylate and local antibiotics, associated with specific systemic antibiotic therapy and a temporary stabilization of the septic non-union. Once the infection is cleared up, the final definitive synthesis is performed. Recently the use of implantable antibiotic medical devices in one step surgery has been introduced with encouraging results and have shown numerous advantages both in terms of management and morbidity for the patient. There are several "pre-formed" devices on the market, which however must be approved by the institution and often have the limit of a high cost in addition to the impossibility of using specific antibiotics. We want to report our experience with a clinical case of a tibial SNU successfully treated by one-step surgery procedure using a custom-made intramedullary antibiotic cement-coated carbon nail. We focus on surgical technique, advantages and pitfalls related to the use of these devices.

A spacer infection by Candida albicans secondary to a Staphylococcus capitis prosthetic joint infection: a case report

BackgroundProsthetic joint infection (PJI) is one of the most feared complications following total arthroplasty surgeries. Gram-positive bacteria are the most common microorganisms implicated in PJIs, while infections mediated by fungi only account for 1% of cases. When dealing with PJIs, a two-stage revision arthroplasty is widely used. Briefly, a spacer is introduced until re-implantation of the definitive prosthesis to provide skeleton stabilization while delivering antibiotics in the site of the infection. Sometimes, antimicrobial therapy may fail, but the isolation of a second microorganism from the spacer is uncommon and even less frequent that of a yeast.Case presentationHere is described a case of a 75-year-old woman who underwent two-stage revision surgery of the left hip prosthesis secondary to a Staphylococcus capitis infection, whose spacer was found to be infected by Candida albicans at a later time. Briefly, the patient underwent revision surgery of the hip prosthesis for a suspected PJI. After the debridement of the infected tissue, an antibiotic-loaded spacer was implanted. The microbiological analysis of the periprosthetic tissues and the implant depicted a S. capitis infection that was treated according to the antimicrobial susceptibility profile of the clinical isolate. Three months later, the patient was admitted to the emergency room due to local inflammatory signs. Synovial fluid was sent to the laboratory for culture. No evidence of S. capitis was detected, however, a yeast was identified as Candida albicans. Fifteen days later, the patient was hospitalized for the removal of the infected spacer. Microbiological cultures confirmed the results of the synovial fluid analysis. According to the susceptibility profile, the patient was treated with fluconazole (400 mg/day) for 6 months. Seven months later, the patient underwent second-stage surgery. The microbiological tests on the spacer were all negative. After 12 months of follow-up, the patient has fully recovered and no radiological signs of infection have been detected.ConclusionsGiven the exceptionality of this complication, it is important to report these events to better understand the clinical outcomes after the selected therapeutic options to prevent and forestall the development of either bacterial or fungal spacer infections.

Ratio of total leukocyte count to C-reactive protein: does it help to differentiate infectious fever from engraftment fever in patients undergoing autologous hematopoietic stem cell transplant?

Engraftment fever (EF) is a common complication of autologous HSCT (AHSCT). It is difficult to discern it from infectious fever (IF). We studied the significance of total blood leucocyte count (TLC) to C-reactive protein (CRP) ratio in differentiating EF from IF. 109 consecutive AHSCT patients were retrospectively analysed between March 2011 and August 2013. Breakthrough fever (BF) was defined as new-onset fever preceded by an afebrile period of at least 48 hours. The BF episodes were classified as IF or EF. Infectious fever was diagnosed in case of blood culture positivity, radiological signs of infection, or fever subsiding within 48 hours of changing the antibiotics. Engraftment fever was defined in cases associated with rising leucocyte counts without identifiable infective focus. EF responded well to steroid therapy. Daily TLC and CRP values were obtained from patients’ records. Optimal cut-off value of ratio on day of BF was obtained by plotting ROC curve. Sensitivity and specificity were calculated at this value. Among 109 cases, the breakthrough fever manifested in seventy patients. The median term for BF was day +9. Sixty-two patients had the EF. Median value of TLC/CRP ratio on the day of BF was significantly higher in patients with EF than with IF (0.139 vs 0.038, p=0.013). With ROC analysis, the AUC value was 0.78 (95%CI – 0.66-0.89, p<0.0001). The ROC curve provided the optimal TLC/CRP value of 0.056. Using a ratio >0.056 for EF, the sensitivity and specificity were 63% (95%CI 50-75%) and 100% (95%CI 63-100%) respectively. TLC/CRP ratio >0.056 is highly specific for EF. Prospective studies are warranted to confirm these findings.

Signs of Pulmonary Infection on Admission Chest Computed Tomography Are Associated With Pneumonia or Death in Patients With Acute Stroke.

Background and Purpose- In patients with acute stroke, the occurrence of pneumonia has been associated with poor functional outcomes and an increased risk of death. We assessed the presence and consequences of signs of pulmonary infection on chest computed tomography (CT) before the development of clinically overt pneumonia. Methods- In 200 consecutive patients with acute ischemic stroke who had CT angiography from skull to diaphragm (including CT of the chest) within 24 hours of symptom onset, we assessed the presence of consolidation, ground-glass-opacity and the tree-in-bud sign as CT signs of pulmonary infection and assessed the association with the development of clinically overt pneumonia and death in the first 7 days and functional outcome after 90 days with logistic regression. Results- The median time from stroke onset to CT was 151 minutes (interquartile range, 84-372). Thirty patients (15%) had radiological signs of infection on admission, and 22 (11.0%) had a clinical diagnosis of pneumonia in the first 7 days. Patients with radiological signs of infection had a higher risk of developing clinically overt pneumonia (30% versus 7.6%; adjusted odds ratios, 4.2 [95% CI, 1.5-11.7]; P=0.006) and had a higher risk of death at 7 days (adjusted odds ratios, 3.7 [95% CI, 1.2-11.6]; P=0.02), but not at 90 days. Conclusions- About 1 in 7 patients with acute ischemic stroke had radiological signs of pulmonary infection within hours of stroke onset. These patients had a higher risk of clinically overt pneumonia or death. Early administration of antibiotics in these patients may lead to better outcomes.

Bone cultures from war-wounded civilians in the Middle East: a surgical prospective.

Hidden infections in a reconstructive surgery program are frequently underestimated. A retrospective study was undertaken of 1,891 civilian war-wounded patients from Iraq, Syria, Yemen and Gaza treated in Amman from August 2006 to January 2016. One thousand three hundred and fifty-three underwent surgical interventions for previous bone injury and had systematic bone cultures. Among patients (167) without any clinical, biological or radiological signs of infection, 46% demonstrated infection based on bone cultures. We conclude that bone culture should become a prerequisite for any reconstruction in such contexts.

Tolerability of High Doses of Daptomycin in the Treatment of Prosthetic Vascular Graft Infection: A Retrospective Study.

IntroductionIn treatment of prosthetic vascular graft infection (PVGI), appropriate antimicrobial treatment is crucial for controlling the septic process and preventing re-infection of the new graft. Glycopeptides are the mainstay of treatment for device-related infections by methicillin-resistant Staphylococcus aureus strains, but with some limitations, especially concerning vancomycin-intermediate and glycopeptide-intermediate S. aureus. We report our experience using a high dose of daptomycin (DAP) for treatment of PVGI.MethodsWe reviewed medical reports of 26 patients treated with high doses of DAP (>8 mg/kg) and beta-lactams/aminosides for PVGI, defined as positive bacterial culture of intraoperative specimens or blood samples and/or clinical, biological, and radiological signs of infection. Clinical success was defined by resolution of all clinical signs at the end of follow-up, without the need for additional antibiotic therapy, and/or negative culture in case of new surgery.ResultsCultures of intraoperative samples were positive in 21 patients (80.8%). Blood and intraoperative cultures were concomitantly positive in 10 patients. The main microorganism identified in microbiological samples was S. aureus (n = 18). Surgery was performed in 23 patients (88.4%). The mean duration of the DAP regimen was 12.3 ± 11.9 days. DAP was discontinued in 26 patients [need to switch to microbiological results (n = 19), bacterial pneumonia (n = 2), and increased creatine phosphokinase levels (n = 4)]. One patient had myalgia, while 9 received concomitant statins.ConclusionHigh-dose DAP therapy shows a satisfactory toxicity profile even in severely ill patients with multiple comorbidities, and may favorably compete with vancomycin, especially concerning the risk of induced nephrotoxicity.Electronic supplementary materialThe online version of this article (doi:10.1007/s40121-014-0035-9) contains supplementary material, which is available to authorized users.

Characteristics and prognosis in patients with prosthetic vascular graft infection: a prospective observational cohort study

Prosthetic vascular graft infection (PVGI) is a devastating complication, with a mortality rate of up to 75%, which is especially caused by aortic graft infection. The purpose of this study was to evaluate factors associated with in-hospital mortality of patients with definite graft infection, and with long-term outcome. We reviewed medical records of 85 patients treated for PVGIs defined by positive bacterial culture of intraoperative specimens or blood samples, and/or clinical, biological and radiological signs of infection. In-hospital patient mortality was defined as any death occurring during the initial treatment of the graft infection. Cure was defined as the absence of evidence of relapsing infection during long-term follow-up (≥1 year). Eighty-five patients (54 aortic and 31 limb graft infections) treated by surgical debridement and removal of the infected prosthesis (n = 41), surgical debridement without removal of prosthesis (n = 34) or antimicrobial treatment without surgery (n = 10) were studied. The only microbiological difference observed between patients with early (occurring within 4 months after surgery) vs. late PVGI and between those with aortic vs. limb PVGI was the incidence of PVGI caused by Staphylococcus aureus, which was greater in patients with limb PVGI. Overall cure was observed in 93.2% of 59 patients with a follow-up of a minimum of 1 year. Overall in-hospital mortality was 16.5% (n = 14). Two variables were independently associated with mortality: age >70 years (OR 9.1, 95% CI 1.83–45.43, p 0.007) and aortic graft infection (OR 5.6, 95% CI 1.1–28.7, p 0.037).

Infected total hip arthroplasty treated by an irrigation-debridement/component retention protocol. A prospective study in a 12-case series with minimum 2 years’ follow-up

Treatment of infection after total hip replacement (THR) is complex and costly. Debridement with component retention is an attractive solution. Success rates in the literature vary widely (18-90%) according to patient selection criteria. The present prospective study assessed the selection criteria used in our department. A prospective study included all patients (n=210) surgically managed for infection following THR between November 2002 and December 2008. Patients underwent debridement in case of acute infection: i.e., early postoperative infection within 1 month of THR, or secondary hematogenic infection with less than 2 weeks' evolution. Beyond this deadline or in case of implant loosening, implant replacement was performed. The debridement series thus comprised 12 patients (mean age, 69 ± 11.3 years; mean evolution from contamination was 4.8 ± 3.5 days). Bacteriologically adapted antibiotherapy was administered for 6 weeks intravenously followed by 6 weeks per os. Mean follow-up was 40 ± 23 months. No patient was lost to follow-up. The success criterion was apparent eradication of infection at a minimum 2 years, defined by absence of clinical, biological or radiological signs of infection and of death attributable to infection or treatment. Where infection was suspected, hip aspiration or peroperative sampling determined recurrence (identical bacterium) or reinfection (different bacterium). There were nine cures (75%) and three failures. Mean Postel Merle d'Aubigné Score, at end of follow-up, was 17 ± 2. The three failures involved the same bacteria (two streptococci [one group B, one group G] and one Enterococcus faecalis) as implicated in the primary infection. The present results are comparable to those in the literature but poorer than for implant exchange. The technique remains, however, an interesting alternative, allowing less complex surgery and lower cost. Patient selection criteria need refining so as to increase success rates with this technique. Level IV; prospective non-randomized non-comparative study.

Detection of Aspergillus species in bone marrow transplant patients

Invasive aspergillosis is a severe complication of cytotoxic chemotherapies and bone marrow transplantation (BMT). The aim of this study was to assess the utility of a real-time PCR assay for the early diagnosis of Aspergillus species in blood samples from BMT patients. Blood specimens (n = 993) from patients (n = 82) scheduled for BMT were collected prior to transplant and for 100 days post transplantation. The specimens were later tested using an Aspergillus-specific real-time PCR assay. Cultures of clinical samples, along with sonography and computerized tomographic scans, were performed as standard of care. Aspergillus DNA was positive in 94 sequential blood samples from 13 patients with clinical and radiological signs of infection. Samples from three of these patients were PCR-positive for Aspergillus in the first week of admission, prior to transplantation. Four patients with aspergillosis were cured with antifungal agents and nine died. An additional 12 patients without clinical signs of infection were PCR-positive on one occasion each, while two patients with clinical signs of infection were PCR-negative. Compared to routine methods of aspergillosis diagnosis, the respective sensitivity, specificity, negative, and positive predictive values of the PCR method by patient were 86.6%, 82%, 96.5% and 52%. The results show that Aspergillus infections in the blood of bone marrow transplant patients can be dectected by PCR methods. Early detection of Aspergillus infections by PCR has the potential to positively impact patient mortality rate and provide cost savings to hospitals.

Right pulmonary artery obstruction due to anastomotic pseudo-aneurysm 23 years after implantation of an aortic prosthesis

Fig. 1. Preoperative images. (a) Chest X-ray. (b) Pulmonary scan with Tc-99mMAA shows absence of right lung perfusion. (c) CT image with intravenous contrast shows obstructed right pulmonary artery due to pseudo-aneurysm behind a prosthetic graft that had been implanted 23 years earlier for acute aortic dissection. These findings were accompanied by elevated D-dimer (38.2 mcg dl ) and dyspnoea over a period of 2 years that had rapidly deteriorated over the past month, followed by sudden pain in the right chest. Emergency surgery was thus required to recover right lung perfusion. Clinical and radiological signs of infection were absent.

Continuous Cefazolin Infusion To Treat Bone and Joint Infections: Clinical Efficacy, Feasibility, Safety, and Serum and Bone Concentrations

Cefazolin has been used for many years to treat bone and joint infections. Because of its time-dependent antimicrobial activity, continuous infusion would potentially be beneficial. We report on the feasibility, safety, and efficacy of prolonged continuous intravenous cefazolin therapy in a cohort of 100 patients, their serum cefazolin levels, and the concomitant bone cefazolin concentrations in 8 of them. This retrospective cohort study included all the patients treated for bone or joint infection with a continuous cefazolin infusion administered over a 12-h period twice daily for >or=2 weeks. Drug monitoring was performed at least twice for all the patients. Serum and bone cefazolin concentrations were determined by standardized disk diffusion microbiological assays. The absence of clinical, biological, and radiological signs of infection after 2 years of follow-up and the same criteria after 1 year of follow-up defined cures and probable cures, respectively. The median treatment duration was 42 days, and the median daily cefazolin dose was 6 g. Half of the patients received parenteral antibiotic therapy on an outpatient basis. Two moderate-grade adverse events were observed. The median serum cefazolin concentrations were 63 microg/ml (range, 13 to 203 microg/ml) and 57 microg/ml (range, 29 to 128 microg/ml) on days 2 to 10 and days 11 to 21, respectively. The median bone cefazolin concentration reached 13.5 microg/g (range, 3.5 to 29 microg/g). The median bone concentration/serum concentration ratio was 0.25 (range, 0.06 to 0.41). Among 88 patients with a median follow-up of 25 months (range, 12 to 53 months), 52 were considered cured and 29 were considered probably cured. Thus, the treatment of bone and joint infections with a prolonged continuous intravenous cefazolin infusion was feasible, effective, well-tolerated, safe, and convenient, making it a strong candidate for home therapy.

Bacterial, Viral and Fungal Infections in Patients after Allogeneic Stem Cell or Bone Marrow Transplantation - A Comparison between Patients with Related and Patients with HLA-Matched Non-Related Stem Cell Donors.

Bacterial, viral and fungal pathogens frequently cause severe, life-threatening infections in immunocompromised patients after allogeneic stem cell transplantation (SCT). We investigated whether patients with related stem cell donors (group A) developed infections less frequently than patients with HLA-matched, non-related donors (group B). Fifty-nine consecutive patients treated at our transplantation unit between April 2004 and January 2005 were included into the analysis. We documented demographic and clinical characteristics at baseline, treatment, clinical course, microbiological examinations, clinical and radiological signs of infection and mortality. Of the total 59 patients analyzed, 22 received stem cells from related and 37 from HLA-matched non-related donors. Both groups were well balanced regarding age and weight. 50% of the patients in group A and 60% in group B were male. Most frequent diagnoses were acute myeloid leukemia (30 of 59 patients [50.8%]; group A: 68.2%; group B: 40.5%), multiple myeloma (15.2%), acute lymphoblastic leukemia (11.9%) and chronic myeloid leukemia (10.2%). Bone marrow was more often the stem cell source in group A (45.5%/ 10 patients) than in group B (10.8%/ 4 patients), peripheral stem cell transplantation respectively was predominant in the unrelated group (86.5%/ 32 patients) versus the family donor group (54.5%/ 12 patients), cord blood was used as unrelated stem cell source in1 patient (2.7%). Clinically documented infections occurred in 6% in group A and in 14% in group B. Pulmonary infiltrates were observed more frequently in group A (11 patients/ 50%) than in group B (16 patients/ 43.2%). The predominant findings were atypical infiltrates (total 16 patients), followed by signs of fungal (total 7 patients) and bacterial pulmonary infiltration (total 4 patients). Microbiologically documented infections were detected in all patients. The average number of pathogens was equal in both groups. Detected pathogens were HHV-6 (48 patients), coagulase-negative Staphylocci (17 patients), EBV (14 patients) and CMV (11 patients). Three fungal infections were detected by microbiological approaches in group A (2 × Candida albicans, 1 × Pitysporum ovale) compared to nine fungal infections in group B (5 × Candida albicans, 1 × Candida glabrata, 1 × Candida parapsilosis, 2 × Geotrichum capitatum). Two years after transplantation, 55.9% of patients were alive (group A: 68.2%; group B: 48.6%). Patients with AML had a two-year survival of 50% (group A: 53.3%; group B: 46.7%). In our study, we observed no clear relation between frequency of infection and donor type, yet there was a trend towards more invasive fungal infections in the unrelated group (13% group A vs. 24% group B).

Stem cell transplantation post invasive fungal infection is a feasible task.

Between March 1997 and January 2002, 18 consecutive patients (18-47 years) with hematological malignancies and previous proven invasive fungal infection underwent stem cell transplantation (SCT) (10 matched sibling allograft, 6 autograft, and 2 haploidentical). All patients had full myeloablative conditioning. The fungal pathogens diagnosed were Aspergillus (14), Fusarium (2), Mucor (1), Exserohilum (1), and Candida (1), involving the lungs (15), sinuses (5), and liver (1). All patients were treated pre- and during transplant with systemic antifungal therapy. Eleven out of 18 (61%) patients survived the transplant. Only 1 of 5 patients who transplanted with an active fungal infection accompanied with active leukemia survived the transplant, compared with 10/13 (84%) survivals in patients who had no clinical and radiological signs of infection or active leukemia (P < 0.025). None of the autografted patients has died, compared with 7/12 allografted patients, of whom 5 underwent transplant with active hematological/active fungal disease. In only 3 patients was the cause of death reactivation of previous fungal infection. Both active fungal infection and active leukemia place patients at a very high risk for procedure-related mortality. Pre-transplant therapy of fungal infection, aiming to achieve a clinically undetectable state of infection, followed by an antifungal treatment during transplant may allow the SCT with no fungal reactivation in selected patients.

Gentamicin coating of metallic implants reduces implant-related osteomyelitis in rats

Antibiotic prophylaxis is a routine procedure in orthopedic surgery. Various local antibiotic delivery techniques are used to reduce bone- and soft tissue-related infection. The objective of this study was to evaluate the efficacy of a new biodegradable, gentamicin-loaded poly( d, l-lactide) (PDLLA) coating of orthopedic devices in preventing implant-related osteomyelitis. The medullary cavities of tibiae in 30 Sprague Dawley rats were contaminated with Staphylococcus aureus (10 3 colony forming units). Simultaneously titanium Kirschner wires, uncoated (group II), coated with PDLLA (group III), or coated with PDLLA + 10% gentamicin (group IV), were implanted. Ten animals that received phosphate-buffered saline and uncoated Kirschner wires served as controls (group I). Follow-up was 6 weeks. In weekly intervals X-rays of the tibiae were performed, blood counts were taken, and body temperature and weight were determined. After sacrifice infection was evaluated by histological and microbiological analysis. All animals of groups II and III developed microbiological, histological, and radiological signs of infection, including osseous destruction and soft tissue swelling. All animals of the control group remained sterile. Cultures of implants of group IV showed significantly reduced bacterial growth compared to cultures of groups II and III, and three implants of group IV remained sterile. Further radiological and histological signs of infection were significantly reduced in the gentamicin-coated group compared to groups II and III. No significant differences in body weight, body temperature, and blood parameters between all groups were observed. Local application of antibiotic-coated orthopedic devices containing PDLLA and 10% gentamicin significantly reduced implant-related infection in this animal model.