Septic Cases Research Articles

The composition of chlorinated or oxidized phosphatidylcholine products changes with hypochlorite concentration: Application to abscess lipid analysis.

Hypochlorous acid, produced by myeloperoxidase upon neutrophil activation, can oxidize various compounds and exert antimicrobial activity in vivo. To elucidate the mechanisms underlying the reactions of the unsaturated phosphatidylcholines, which abound in cell membranes, with hypochlorous acid, we identified and examined phosphatidylcholine chlorination and oxidation products formed under various reaction conditions. We first investigated the products of unsaturated phosphatidylcholine and hypochlorous acid reaction with respect to hypochlorite concentration and reaction time. Next, we examined the lipids extracted postmortem from human abscesses. For all the analyses, we used liquid chromatography-quadrupole time-of-flight mass spectrometry. Various compounds, including phosphatidylcholine chlorohydrin and phosphatidylcholine hydroxide/epoxide, were detected. Oxidized phosphatidylcholines were mainly detectable upon reaction with low concentrations of sodium hypochlorite, whereas chlorinated phosphatidylcholines formed in the presence of higher concentrations. In human abscesses, oxidized phosphatidylcholines were detected in the cases with high procalcitonin concentration, whereas chlorinated phosphatidylcholines were undetected. The detections of oxidized phosphatidylcholines in human tissues might indicate previous exposure to hypochlorous acid in septic cases. Our results provide insight into the mechanisms underlying pathogen survival following inflammation associated with neutrophil activation and topical myeloperoxidase release and show postmortem biomarkers candidates for sepsis.

Electroencephalographic Grading of Neuronal Dysfunction in Various Etiologies of Encephalopathy.

The objective of this work was to study the electroencephalographic (EEG) grading of neuronal dysfunction in encephalopathy of various etiologies and assess their association with clinical outcomes. This retrospective cross-sectional study was performed between June and November 2018 at the Neurology Department of King Fahd Hospital of University, Kingdom of Saudi Arabia (KSA) and involved a review and analysis of EEG and medical records pertaining to 222 patients in whom encephalopathy was diagnosed. In patients suffering from encephalopathy, advanced age (P = .01), low Glasgow Coma Scale (GCS) scores (P = .00), and certain etiologies, namely hypoxic-ischemic encephalopathy (HIE) (P = .00), septic encephalopathy (P = .01), and other illnesses (P = .00), were significantly associated with unfavorable clinical outcomes, whereas traumatic brain injury (TBI) (P = .01) and GCS >7 (P = .00) were associated with favorable outcomes. Among different etiologies, EEG grade I (P = .02) and grade IV (P = .04) neuronal dysfunction was significantly associated with TBI while grade III (P = .05) and grade V (P = .02) neuronal dysfunction was significantly associated with HIE. Grade I (P = .03) neuronal dysfunction was mostly observed in septic encephalopathy cases, while patients suffering from other illnesses were also found to have grade I (P = .04) and grade IV (P = .05) neuronal dysfunction based on their EEG. EEG is being conducted routinely to determine the course and severity of various forms of encephalopathy. However, the clinical implications of EEG grading for neuronal dysfunction are largely dependent on underlying etiology and other clinical parameters, such as age and GCS score. Further larger prospective cohort studies involving other important prognostic parameters and continuous EEG monitoring are thus needed.

Hospital Stays and Medical Expenses Increase Nationwide Among Patients With Septic Arthritis of the Shoulder Who Inject Drugs.

The authors determined the proportion of patients nationwide with septic arthritis of the shoulder who inject drugs, evaluated differences in hospitalization outcomes and charges between patients with and without injection drug use (IDU), and quantified demographic trends among patients with IDU from 2000 to 2013. Nationally representative data of patients with a principal discharge diagnosis of shoulder septic arthritis were obtained from the Nationwide Inpatient Sample 2000-2013. Using published algorithms, the authors classified septic arthritis of the shoulder as related or unrelated to IDU. They compared length of stay, leaving against medical advice, number of procedures, and mortality rates between the 2 groups, using regression models to control for age, sex, and race. Fifteen percent (95% confidence interval [CI], 13.6%-16.5%) of septic arthritis cases were associated with IDU. From 2000 to 2013, shoulder septic arthritis associated with IDU increased 4-fold. After controlling for age, sex, and race, individuals who inject drugs stayed in the hospital for 3.7 more days (95% CI, 2.4-5.0), incurred an average of $13,250 more charges for medical care (95% CI, $2635-$23,866), and were 5.54 times more likely (95% CI, 3.22-9.55) to leave against medical advice than those without IDU. From 2000 to 2013, there was an increase in the proportion of patients with IDU-related septic arthritis of the shoulder between 35 and 54 years old and 55 and 64 years old, and an increase in the proportion who were white. Injection drug use-related shoulder septic arthritis is linked to suboptimal inpatient outcomes and greater resource use. [Orthopedics. 2020;43(4):e270-e277.].

Outcome of Septic Abortion –Experience from a Tertiary Referral Hospital

Objective: Septic abortion is a life threatening complication of induced abortion. Being a tertiary referral hospital in Bangladesh, Sir Salimullah Medical College and Mitford Hospital often deals with such cases of septic abortion. This research work was conducted with the aim of evaluation of frequency, complications and outcome of septic abortion in this institute.
 Method: A cross sectional observational study was conducted from January 2016 to December 2016 in the department of Obstetrics and Gynaecology, Sir Salimullah Medical College and Mitford Hospital, Bangladesh. All cases of septic abortion admitted in the department were included in the study.
 Results: During one-year period total number of Gynaecological admission cases were 11,351, of which 1065 were abortion cases, among them 28 cases were diagnosed as septic abortion. The frequency of septic abortion thus was 2.6% of the abortion admitted cases. Age range of the patients was between 15 to 45years. Majority (60.71%) of the cases were grand multigravida, belonging to poor socioeconomic group (71%). Most of the patients (68%) came with haemorrhage. The most frequent method (50%) used for termination of pregnancy in this study was Menstrual Regulation (MR) in unhygienic environment. Mostly (57.14%) the patients were managed by evacuation and curettage. Laparotomy was also needed for the definitive management of two patients. Maternal mortality in this study group was one out of 28(3.7%).
 Conclusion: Septic abortion contributes significantly to maternal morbidity and mortality. Proper use of contraceptives, avoidance of induced abortion in unhygienic condition can reduce the moribund consequences. In this study one maternal death among 28 septic abortion cases indicate proper standard of care of the hospital.
 Bangladesh J Obstet Gynaecol, 2020; Vol. 35(1): 3-6

Septic Arthritis and the Opioid Epidemic: 1465 Cases of Culture-Positive Native Joint Septic Arthritis From 1990-2018.

BackgroundThe clinical spectrum of septic arthritis in the era of the opioid crisis is ill-defined.MethodsThis is a retrospective chart review of 1465 cases of culture-positive native joint septic arthritis at Boston teaching hospitals between 1990 and 2018.ResultsBetween 1990–2008 and 2009–2018, the proportion of septic arthritis cases involving people who inject drugs (PWID) rose from 10.3% to 20% (P < .0000005). Overall, methicillin-sensitive Staphylococcus aureus (MSSA) caused 41.5% of cases, and methicillin-resistant Staphylococcus aureus (MRSA) caused 17.9%. Gram-negative rods caused only 6.2% of cases. Predictors of MRSA septic arthritis included injection drug use (P < .001), bacteremia (P < .001), health care exposure (P < .001), and advancing age (P = .01). Infections with MSSA were more common in PWID (56.3% vs 38.8%; P < .00001), as were infections with MRSA (24% vs 16.8%; P = .01) and Serratia sp. (4% vs 0.4%; P = .002). Septic arthritis in the setting of injection drug use was significantly more likely to involve the sacroiliac, acromioclavicular, and facet joints; 36.8% of patients had initial synovial fluid cell counts of <50 000 cells/mm3.ConclusionsInjection drug use has become the most common risk factor for septic arthritis in our patient population. Septic arthritis in PWID is more often caused by MRSA, MSSA, and Serratia sp., and is more prone to involve the sacroiliac, acromioclavicular, sternoclavicular, and facet joints. Synovial fluid cell counts of <50 000 cells/mm3 are common in culture-positive septic arthritis.

The Prevalence, Risk Factors, and Bacterial Profile of Cesarean Surgical Site Infections at a University Teaching Hospital in South Western Uganda

Introduction: The single most important risk factor for post-partum maternal infection is Cesarean section (C/S) with a 5-20-fold greater risk for infection compared to a vaginal delivery. Post Cesarean wound infection is diagnosed in 2.5 to 16 percent of patients. Early wound infections (in the first 24 to 48 hours) are usually due to group A or B beta-hemolytic streptococcus and are characterized by high fever and cellulitis while later infections are likely due to Staphylococcus epidermises or aureus, Escherichia coli, or Proteus species. Objectives: To determine the prevalence, risk factors and bacterial profile of wound sepsis following Cesarean at Mbarara Regional Referral Hospital (MRRH). Methods: A cross sectional study of mothers who delivered by Cesarean at MRRH was conducted. Mothers were recruited consecutively until the sample size was achieved. The main dependent variable was wound sepsis confirmed by a positive culture for microorganisms. Results: Of the 359 mothers recruited in the study, 54 (15.5%) developed Cesarean wound sepsis. The risk factors associated with post Cesarean wound sepsis were severe anemia, lack of preoperative antibiotics use, poor antenatal attendance, mothers referred from peripheral health facilities, abnormal Body Mass Index (BMI), diabetes mellitus, more than five vaginal examinations, prolonged rupture of membranes before C/S, and prolonged labour. Staphylococcus aureus was isolated in 48.2% of all the septic cases and most of the bacterial isolates were susceptible to ceftriaxone, ceftazidime, ciprofloxacin and nalidixic acid and resistant to penicillin. Conclusion: The prevalence of post Cesarean wound sepsis is high with staphylococcus aureus being the most common bacteria isolated in infected wounds. Most of the bacteria were susceptible to third generation cephalosporins and quinolones. Antibiotics use was protective against developing wound sepsis.

Acides hyaluroniques dans la gonarthrose, les autres localisations arthrosiques et en extra-articulaire

Hyaluronic acid is a glycosaminoglycan, one of the main components of the extra-cellular matrix and synovial fluid, produced by synoviocytes. It plays a role in maintaining joint fluid viscoelasticity and is a shock absorber, and helps cartilage to be resistant. It plays also a role for synovial fluid lubrification. In osteoarthritis (OA), molecular weight and concentration are reduced. Its use in human clinic, in rheumatology, by intra-articular injections in knee OA dates back to 1970s. Evidences for IAHA efficacy in knee OA are numerous: more than 80 randomized controlled trials, of which a majority versus placebo, and now 17 meta-analyses of placebo-controlled trials show a symptomatic efficacy, with an effect size on pain reduction ranging from 0.37 to 0.63. According to a recent meta-analysis, safety is excellent, with no peculiar issue, but 8.5 to 10 % local painful reaction, redness, and modest swelling after injection. No systemic effect has been reported. Few post-injection septic arthritis cases have been reported. But there are pseudo-septic arthritis looking like septic arthritis, but with no such hard outcome. Therefore, benefit-risk of IAHA is very positive. Around 20 preparations are currently available in France, either in three- or mono-injections, differing by their molecular weight, their concentration, their biochemical structure, their price. Despite efficacy evidence, international treatment recommendations provide a most contrasted advice on IAHA use and place in knee OA therapeutic management. HA may be used in other OA locations than knee, such as hip, shoulder, ankle, thumb base, 1st metatarsal joint, and are also proposed in the treatment of tendinopathies with current low and variable level of evidence, however really weak, or non existing.

The Utility of Serum d-Dimer for the Diagnosis of Periprosthetic Joint Infection in Revision Total Hip and Knee Arthroplasty

BackgroundThere is scarce and contradicting evidence supporting the use of serum d-dimer for the diagnosis of periprosthetic joint infection in revision total hip (THA) and knee (TKA) arthroplasty. Therefore, the purpose of this study is to test the accuracy of serum d-dimer against the 2013 International Consensus Meeting (ICM) criteria. MethodsA retrospective review was performed on a consecutive series of 172 revision THA/TKA surgeries performed by 3 fellowship-trained surgeons at a single institution (August 2017 to May 2019) and that had d-dimer performed during their preoperative workup. Of this cohort, 111 (42 THAs/69 TKAs) cases had complete 2013 ICM criteria tests and were included in the final analysis. Septic and aseptic revisions were categorized per 2013 ICM criteria (“gold standard”) and compared against serum d-dimer using an established threshold (850 ng/mL). Sensitivity, specificity, likelihood ratios, and positive/negative predictive values were determined. Independent t-tests, Fisher’s exact tests, chi-squared tests, and receiver operating characteristic curve analysis were performed. ResultsThere was no statistically significant difference in baseline demographics between septic and aseptic cases per 2013 ICM criteria. When compared to ICM criteria, d-dimer demonstrated high sensitivity (95.9%) and negative predictive value (90.9%) but low specificity (32.3%), positive predictive value (52.8%), and overall, poor accuracy (61%) to diagnose periprosthetic joint infection. Positive likelihood ratio was 1.42 while negative likelihood ratio was 0.13. The area under the curve (AUC) was 0.742. ConclusionSerum d-dimer has poor accuracy to discriminate between septic and aseptic cases using a described threshold in the setting of revision THA and TKA.

Correlation between Neutrophil Gelatinase‐associated Lipocalin and highly sensitive C reactive protein as markers for early detection of acute kidney injury in neonatal sepsis.

Introduction Sepsis is the commonest cause of neonatal mortality and is responsible for 30-50% of total neonatal deaths each year in developing countries. Neonatal sepsis is one of the commonest causes of Acute Kidney Injury (AKI) in newborns and it is associated with poor outcomes. Aim of the study To investigate the value of Neutrophil Gelatinase-associated Lipocalin and highly sensitive C reactive protein as markers for early detection of acute kidney injury in neonatal sepsis. Patients and Methods This prospective study was conducted on 50 neonates admitted to the Neonatal Intensive Care Unit with neonatal sepsis at our university hospital (GI) and 30 apparently healthy neonates matched for gestational age and weight as a control group (GII). The septic group (GI) included all neonates (age 5-28 days) with neonatal sepsis and were classified into two subgroups according to the presence of AKI. After detailed history and complete clinical examination, all cases were subjected to the following investigations: CBC, ABG, blood culture, serum electrolytes and creatinine, CRP, hs-CRP and NGAL. Results Only 64%of all septic cases showed positive qualitative CRP (> 6mg/L) while 86% of them showed positive hs-CRP of ( > 0.5mg/L) with highly significant differences (p < 0.001). Blood culture was positive only in 52% of cases. In this study, hs-CRP was significantly higher in septic neonates with AKI (27 cases) than those without AKI (16 cases) (p < 0.001). NGAL level was significantly higher in septic neonates than the control group (p < 0.001). Also NGAL level was markedly elevated in septic cases with AKI compared to non AKI subgroup with highly significant differences (p < 0.001).There was a positive correlation between NGAL and hs-CRP in septic cases with AKI. Conclusion Hs-CRP was proved to be very useful biochemical marker for early detection of neonatal sepsis compared to qualitative CRP. Serum NGAL and hs-CRP can be considered as very useful biochemical markers for early detection of AKI in septic neonates before any rise in serum creatinine.

Heterotopic Ossification in Orthopaedic and Trauma surgery: A Histopathological Ossification Score

Heterotopic Ossification (HO) is a potential long-term complication in orthopaedic surgery. It is commonly classified according to the Brooker classification, which is based on radiological findings. To our knowledge the correlation of histological features to the Brooker grade is unknown as is the association between HO and the indication for revision. The aim of this paper is to analyze the ossification grade of HO tissue in patients undergoing revision hip and knee arthroplasty and to propose a histologically based classification system for HO. We also assess the relationship between the grade of HO and the indication for revision (septic and aseptic revision). From January to May 2019 we collected 50 human HO samples from hip and knee revision arthroplasty cases. These tissue samples were double-blinded and sent for histopathological diagnostic. Based on these results, we developed a classification system for the progression of HO. The grade of ossification was based on three characteristics: Grade of heterotopic ossification (Grade 1–3), presence of necrosis (N0 or N1) and the presence of osteomyelitis (HOES-Score Type 1 to 5). Demographic data as well as surgical details and indication for surgery was prospectively collected from clinical records. Fifty tissue samples were harvested from 44 hips and 6 knee joints. Of these 33 exhibited Grade I ossifications (66%), followed by 11 Grade II (22%) and one Grade III (2%). Necrosis was noted in two tissue samples (4%) and 2 more had osteomyelitis findings according to HOES-Score. Six samples (12%) with radiologically suggestive of HO turned out to be wear-induced synovitis, SLIM Type 1. Of these cases 16 were septic (32%) and 34 aseptic (68%) revisions. Most of the HO tissue samples were classified as a low-grade. High-grade ossification-Score is rare. Higher grades of ossification seem to be associated with septic revision cases. Wear-induced synovitis potentially influences HO development. A histological scoring system for ossification grading can be derived from the data presented in this study.

Appropriateness of antimicrobial use among septic patients managed by the critical care response team: an opportunity for improvement through de-escalation

BackgroundMost septic patients managed by critical care response teams (CCRT) are prescribed antimicrobials. Nevertheless, data evaluating their appropriateness are lacking both locally and internationally. The objective was to assess antimicrobial use among septic and non-septic patients managed by CCRT.SettingCase-control design was used to compare septic (cases) and non-septic (controls) CCRT patients at tertiary care setting. The frequency of antimicrobial use was assessed before and after CCRT activation. The appropriateness of antimicrobial use was assessed at day four post-CCRT, based on standard recommendations, clinical assessment, and culture results.Main resultsA total of 157 cases and 158 controls were included. The average age was 61.1 ± 20.4 years, and 54.6% were males, with minor differences between groups. The use of any antimicrobial was 100.0% in cases and 87.3% in controls (p < 0.001). The use of meropenem (68.2% versus 34.8%, p < 0.001) and vancomycin (56.7% versus 25.9%, p < 0.001) were markedly higher in cases than controls. The overall appropriateness was significantly lower in cases than controls (50.7% versus 59.6%, p = 0.047). Individual appropriateness was lowest with meropenem (16.7%) and imipenem (25.0%), and highest with piperacillin/tazobactam (87.1%) and colistin (78.3%). Only 48.5% of antimicrobials prescribed by CCRT were de-escalated by a primary team within four days. Individual appropriateness and de-escalations were not different between groups.ConclusionsEmpiric use and inadequate de-escalation of broad-spectrum antimicrobials were major causes for inappropriate antimicrobial use in CCRT patients. Our findings highlight the necessity of urgent implementation of an antimicrobial stewardship program, including training and auditing of antimicrobial prescriptions.

Pediatric Septic Arthritis of the Knee: Predictors of Septic Hip Do Not Apply

The early diagnosis of pediatric septic arthritis is paramount to the prevention of long-term sequela. The purpose of this study is to investigate if the commonly used criteria developed by Kocher and colleagues for hip septic arthritis can be used for screening children with suspected septic knee. We retrospectively reviewed the charts of patients under the age of 19, between June 2002 to June 2017, who presented to a major tertiary-care children's hospital with septic knee. Diagnostic criteria included either a positive synovial culture from the knee, synovial white blood cell (WBC)>50,000 cells/mm, or synovial WBC count >25,000 cells/mm and clinical agreement of diagnosis from Infectious Disease and Orthopaedic colleagues. Collected data included the initial criteria described by Kocher and colleagues: history of fever, non-weight-bearing, erythrocyte sedimentation rate, and serum WBC as well as a recently modified criterion: C-reactive protein. Univariate analysis was used to determine the quality of these variables in ruling out septic knee. One hundred four patient charts were found to meet our inclusion criteria demonstrating C-reactive protein>20 mg/L (75%), fever (65%), non-weight-bearing status (64%), erythrocyte sedimentation rate>40 mm/h (60%), and WBC>12,000 cells/mm (49%). With the 25 different combinations of these predictors adjusted for, in an escalating manner, 0 predictors suggested a sensitivity of 0.02, 1 predictor a sensitivity of 0.06, 2 predictors a sensitivity of 0.2, 3 predictors a sensitivity of 0.32, 4 predictors a sensitivity of 0.3, and 5 predictors a sensitivity of 0.11. According to the Kocher criteria of the hip, at 3 or more criteria the probability of septic arthritis becomes 93% with a sensitivity of 0.84 provoking many physicians to use this cutoff in their assessment of hip pain. This study suggests that if these criteria were applied to the knee, 52% of septic knee cases could be missed. There is a need for further investigation of specific criteria of the knee as the markers of the hip septic arthritis are not necessarily applicable in the knee. Level III.

Investigating Transfusion-related Sepsis Using Culture-Independent Metagenomic Sequencing.

BackgroundTransfusion-related sepsis remains an important hospital infection control challenge. Investigation of septic transfusion events is often restricted by the limitations of bacterial culture in terms of time requirements and low yield in the setting of prior antibiotic administration.MethodsIn 3 gram-negative septic transfusion cases, we performed metagenomic next-generation sequencing (mNGS) of direct clinical blood specimens in addition to standard culture-based approaches utilized for infection control investigations. Pathogen detection leveraged IDSeq, a new open-access microbial bioinformatics portal. Phylogenetic analysis was performed to assess microbial genetic relatedness and understand transmission events.ResultsmNGS of direct clinical blood specimens afforded precision detection of pathogens responsible for each case of transfusion-related sepsis and enabled discovery of a novel Acinetobacter species in a platelet product that had become contaminated despite photochemical pathogen reduction. In each case, longitudinal assessment of pathogen burden elucidated the temporal sequence of events associated with each transfusion-transmitted infection. We found that informative data could be obtained from culture-independent mNGS of residual platelet products and leftover blood specimens that were either unsuitable or unavailable for culture or that failed to grow due to prior antibiotic administration. We additionally developed methods to enhance accuracy for detecting transfusion-associated pathogens that share taxonomic similarity to contaminants commonly found in mNGS library preparations.ConclusionsCulture-independent mNGS of blood products afforded rapid and precise assessment of pathogen identity, abundance, and genetic relatedness. Together, these challenging cases demonstrated the potential for metagenomics to advance existing methods for investigating transfusion-transmitted infections.

Presence of Propionibacterium acnes in patients with aseptic bone graft resorption after cranioplasty: preliminary evidence for low-grade infection.

Autologous bone graft reimplantation remains the standard treatment after decompressive hemicraniectomy. Unfortunately, some patients present with signs of bone resorption without any visible signs of infection; the reasons remain unknown. Contamination with Propionibacterium acnes has been discussed as a potential source of the osteolytic process. The aim of this study was to investigate the microbial spectrum detected in samples of grafts from patients with aseptic bone resorption and compare them to septic bone graft infections in order to identify P. acnes as the specific pathogen of aseptic bone resorption. The authors retrospectively reviewed all patients treated for aseptic bone resorption between 2012 and 2017 in their neurosurgical department. Septic infections were used as a control group to gain information on the present bacterial spectrum. Perioperative data such as demographics, number of surgeries, and complications were assessed and compared with the microbiological analyses conducted in order to detect differences and potential sources for aseptic bone resorption and possible differences in bacterial contamination in septic and aseptic bone infection. In total, 38 patients underwent surgery between 2012 and 2017 for septic bone infection-14 for aseptic bone resorption. In 100% of the septic bone infection cases in which bone flap removal was needed, bacteria could be isolated from the removed bone flap (55% Staphylococcus aureus, 13.2% Enterococcus faecalis, and 18.4% Staphylococcus epidermidis). The microbial spectrum from samples of aseptic bone flaps with resorption was examined in 10 of 14 patients and revealed contamination with P. acnes in 40% (n = 4, the other 6 bone grafts were sterile), especially in sonication analysis, whereas visible septic bone infection was mainly caused by S. aureus without detection of P. acnes. Aseptic bone resorption may be caused by low-grade infections with P. acnes. However, further analysis needs to be conducted in order to understand its clinical relevance and treatment perspective.

The clinical decision support system for sepsis as an important part of the medical and economic component of a hospital

Aim: To evaluate an impact of a clinical decision support system (CDSS) in the clinical practice of a hospital on the quality and costs of treatment of patients with severe sepsis and septic shock.Materials and methods: We performed a retrospective analysis of the database in the medical information system qMS (SP.ARM, Russia, St. Petersburg) from 2015 to 2017 on 37,997 patients. In the first study period from January 2015 to June 2016, we analyzed the results of the conventional treatment regimen. From May to June 2016, the CDSS module was implemented into the qMS and the personnel was trained correspondingly. The data collected during the second study period mirrored the results of sepsis treatment with the use of CDSS. We assessed the average number of in-hospital days, duration of stay in the intensive care unit, number of septic shock cases, mortality, and treatment costs.Results: The diagnosis of sepsis was confirmed in 67 patients: in 1.4‰ (27/18,792) before the CDSS was implemented versus 2.1‰ (40/19,205) after the CDSS implementation (p &lt; 0.01). It was found that the use of CDSS integrated into the hospital medical information system reduced the number of cases of septic shock development (p &lt; 0.05). Lethality decreased by 10%. The sepsis-associated mortality showed a non-significant trend to decrease by 10% (p &lt; 0.1). The implementation of the CDSS incorporated into the qMS helped to reduce the number of septic shock cases from 26% (7/27) to 7.5% (3/40) (p &lt; 0.05). There was also a trend towards reduced duration of stay in intensive care unit, as well as towards decreased costs of sepsis treatment by 13% and efferent (extra-corporeal) treatments by 29%; however, the differences were not significant.Conclusion: The CDSS implementation for electronic monitoring of the patient's condition and changes in his/hers parameters allowed for an earlier diagnosis of sepsis. We identified some prerequisites for more rational utilization of medical resources, mainly due to early, targeted treatment of patients with severe sepsis and septic shock; however, additional studies are necessary.

Determining the Risk of Septic Arthritis Following Intra-Articular Injection of Drugs Mixed At A Tertiary Care Center, 2012–2017

BACKGROUND Intra-articular corticosteroid injections are commonly used for the outpatient treatment of osteoarticular pain. Practitioners may choose to administer additional medications such as anesthetics. While medications are compounded in the pharmacy following stringent environmental requirements, occasionally injections with additional components for immediate use are mixed at the point of care under less strict environmental conditions due to turnaround time requirement. We assessed if mixing multiple drugs in a single syringe in outpatient settings was associated with subsequent septic arthritis. METHODS We reviewed electronic pharmacy medication administration records of patients who received an intra-articular corticosteroid injection at a tertiary care center during 2012–2017. We extracted basic patient demographics. Exposure was defined as receiving more than one intra-articular medication during a single injection-encounter. The outcome was culture-confirmed septic arthritis defined as a?positive synovial fluid culture within 90?days following an intra-articular?injection. We present case counts, ranges, and frequencies. RESULTS 7,072 unique patients received an intra-articular injection. Mean age was 55?years (range: 9 – 104) and 41% were male. There were 13,089 distinct intra-articular injection-encounters. Of the unique encounters, 306 (2%) intra-articular injection involved only one medication; 12,080 (92%) received 2 medications; 596 (5%) received 3 medications; 104 (0.8%) received 4 medications; and 3?(0.02%) received 5 medications. There were no infections following single intra-articular medication injection-encounters. Two septic arthritis cases were identified in patients who received two intra-articular medications (triamcinolone and lidocaine 1%). The microorganisms were: Staphylococcus aureus and Enterobacter cloacae. CONCLUSIONS Intra-articular corticosteroid injection practices in outpatient settings are heterogeneous. Septic arthritis following intra-articular injection was infrequent. We were unable to associate septic arthritis with mixing intra-articular injectables outside the pharmacy.

Pseudoartrosi settiche e asettiche dell’arto inferiore

Nonunion is a dangerous orthopaedic complication. The purpose of this work was to provide an indication for the diagnosis, classification and treatment of nonunions. The technique for treating aseptic nonunions depends on viability of the site. Therapeutic intervention create a mechanical and biological situation positive to achieve the treatment. In septic cases, the method consists in oncological debridement of bone and soft tissue and reconstructive surgery. Circular fixation plays an active role.

A comparative study of intraoperative frozen section and alpha defensin lateral flow test in the diagnosis of periprosthetic joint infection

Background and purpose — For decision-making (aseptic vs. septic), surgeons rely on intraoperatively available tests when a periprosthetic joint infection (PJI) cannot be confirmed or excluded preoperatively. We compared and evaluated the intraoperative performances of the frozen section and the alpha defensin lateral flow test in the diagnosis of PJI.Patients and methods — In this prospective study, consecutive patients with indicated revision surgery after arthroplasty were included. Patients were classified as having PJI using the MusculoSkeletal Infection criteria. The presence of alpha defensin was determined using the lateral flow test intraoperatively. During revision surgery, tissue samples were harvested for frozen and permanent section. Analysis of diagnostic accuracy was based on receiver-operating characteristics.Results — 101 patients (53 hips, 48 knees) were eligible for inclusion. Postoperatively, 29/101 patients were diagnosed with PJI, of which 8/29 cases were definitely classified as septic preoperatively. Of the remainder 21 septic cases, the intraoperative alpha defensin test and frozen section were positive in 13 and 17 patients, respectively. Sensitivities of the alpha defensin test and frozen section were 69% and 86%, respectively. The area under the curves of both tests showed a statistically significant difference (p = 0.006).Interpretation — The frozen section showed a significantly higher performance compared with the alpha defensin test and a near perfect concordance with the definitive histology, and therefore remains an appropriate intraoperative screening test in diagnosing PJI. Although the sensitivity of the alpha defensin test was lower compared with that of frozen section, this test is highly specific for confirming the diagnosis of PJI.

Arthrotomy and Lavage of Neonatal Septic Arthritis - A Multicenteric Study

Background: Acute septic arthritis (SA) of childhood is a potentially devastating disease that may cause permanent disability or even death, especially in resource - limited settings. Septic arthritis is rare in developed countries, the annual incidence being 4 cases p er 1,00,000 but is considerably more common in lower socioeconomic groups. Objective: To study about the septic arthritis in neonates using arthrotomy &amp; lavage and the complications associated with septic arthritis. Materials and Methods : A total of 319 n eonates with septic arthritis irrespective of the joint involved, admitted to NICU in School of Medical Sciences and Research , Madras Medical College and Mohan Kumaramangalam Medical College for a period of three consecutive years were taken up for the stu dy. All suspected cases of neonatal septic arthritis were subjected for detailed clinical history, examination, hematological and radiological investigations were done. All suspected cases were started with empirical or culture specific IV antibiotics for 2 weeks. The neonates who responded to the treatment given within 48 – 72 hours were treated conservatively and excluded from our study. The neonates who did not respond to the antibiotics given were subjected for arthrotomy and lavage of the affected join t. The aspirated material was sent for culture and sensitivity for specific antibiotic treatment. The treatment was given with culture specific IV antibiotics for a minimum period of 2 weeks followed by oral antibiotics for a period of 2 weeks from the tim e symptoms subsides. All cases were followed up at a monthly interval to a minimum period of 1 year of their age. Results: A total of 512 septic arthritis cases were seen in infants of whom 319 cases were neonates during the three year study period. The m ost common organism causing neonatal septic arthritis in our study was Staphylococcus aureus in 116 cases (36.36%). No organism was cultured in 81 cases (25.39%). Viral or fungal or anaerobes or reactive arthritis might be responsible for this 25.39% cases . Concomitant osteomyelitis was found in 5 cases in hip % 1 case in knee. Tomsmith arthritis of hip was found in 2 cases. Mild joint stiffness were found in 7 cases in hip, 3 cases in knee, 1 case in shoulder and 1 case in ankle seen at follow up. After di scharge gentle passive joint motion were advised. The missed cases from follow up were not included in the study. Conclusion: The sequelae of septic arthritis in neonates can be prevented by early diagnosis and early intervention with emergency lavage of any involved joint to reduce the rate of disability. The arthrotomy and lavage is the definitive treatment for neonatal septic arthritis which reduce the morbidity and mortality of the neonates.

Measurements of C-Reactive Protein for Successful Management and Follow-Up Treatment of Neonatal Sepsis and Nosocomial Infection

Objective: To develop an optimal follow-up treatment for neonatal and nosocomial infections and to examine correlations between the C-reactive protein (C-RP) and platelets. Methods: A sample of 27 septic neonates and 14 non-septic neonates were selected for this study. The non-septic neonates served as a control group. Blood samples were collected from both groups and analyzed for bacterial contamination via blood culture, complete blood count (CBC), and C-RP, according to international laboratory standards. Blood collection and analysis were repeated every day during the follow-up treatments with antibiotics to evaluate the kinetics of C-RP. Results: Blood culture found E. coli and Staphylococcus aureus in the blood of the septic cases. Serum C-RP concentrations were at high levels (24 mg/dl) in the septic neonates and at normal levels (lower than 6 mg/dl) in the control group. Treatment with active antibiotics resulted in a drastic reduction of the C-RP values and helped to reach a normal level as in the control group. On the other hand, there were increases in the platelet levels as the C-RP levels decreased. This result indicates a strong negative association between C-RP and platelet levels in the septic group only. Statistical analysis shows significant differences between the mean C-RP serum concentrations of the sepsis and non-sepsis. Conclusion: blood culture, active antibiotics, and kinetic C-RP measurements during the medical follow-up treatment are strong driving parameters for the optimal and successful management of sepsis.