Specific Antibiotic Treatment Research Articles

One-stage exchange

Based on the first implementation of mixing antibiotics into bone cement in the 1970s, the Endo-Klinik has used one stage exchange for prosthetic joint infection (PJI) in over 85% of cases. Looking carefully at current literature and guidelines for PJI treatment, there is no clear evidence that a two stage procedure has a higher success rate than a one-stage approach. A cemented one-stage exchange potentially offers certain advantages, mainly based on the need for only one operative procedure, reduced antibiotics and hospitalisation time. In order to fulfill a one-stage approach, there are obligatory pre-, peri- and post-operative details that need to be meticulously respected, and are described in detail. Essential pre-operative diagnostic testing is based on the joint aspiration with an exact identification of any bacteria. The presence of a positive bacterial culture and respective antibiogram are essential, to specify the antibiotics to be loaded to the bone cement, which allows a high local antibiotic elution directly at the surgical side. A specific antibiotic treatment plan is generated by a microbiologist. The surgical success relies on the complete removal of all pre-existing hardware, including cement and restrictors and an aggressive and complete debridement of any infected soft tissues and bone material. Post-operative systemic antibiotic administration is usually completed after only ten to 14 days.

Systematic PCR Detection in Culture-negative Osteoarticular Infections

BackgroundIdentification of microorganisms is crucial for the successful treatment of osteoarticular infections. Molecular methods are more sensitive than culture-dependent methods but may suffer from lack of specificity. MethodsWe studied a large series of 3840 bone and joint culture-negative samples collected from 2308 patients hospitalized in Marseille University Hospitals from November 2007 to October 2009. The samples were systematically cultured for 15 days, and conventional broad-range polymerase chain reaction (PCR) (16S rDNA and 18S rDNA) as well as real-time PCR assays targeting human Bglobin, Staphylococcus aureus, and Kingella kingae were realized on one culture-negative specimen. ResultsSpecimens from 741 patients (32.1%) tested positive by culture, including 38 in which bacteria grew only after 6 days of incubation. PCR was positive in 141 (9%) culture-negative specimens. Microorganisms identified by PCR were classified into 2 groups: fastidious bacteria (n = 35), mostly anaerobes in adult patients, and K. kingae in children; and nonfastidious bacteria (n = 106), mostly S. aureus (32.7%). A discrepancy between a positive PCR result for S. aureus and a negative culture were explained by previous antibiotherapy in 31.4% of cases. Our study highlights the usefulness of systematic 16S rDNA gene PCR for the diagnosis of bone and joint infections in culture-negative patients, thus enabling the administration of specific antibiotic treatments. ConclusionsWe recommend the use of conventional broad-range PCR for culture-negative bone and joint specimens, as well as S. aureus-specific PCR for adults and K. kingae-specific PCR for children. 18S rDNA PCR should be reserved only for specific cases.

Clinical differences in Clostridium difficile infection based on age: A multicenter study

Advancing age is a well-known risk factor for Clostridium difficile infection (CDI). However, age-specific clinical differences in CDI are uncertain. A retrospective comparative analysis was performed based on age in 1367 patients with CDI in Korea. Most clinical features were similar in the two age groups studied, however malignancy was more common in the older group (age ≥ 65 y) (p < 0.001), while chemotherapy and transplantation were more common in the younger group (age < 65 y) (p < 0.001). Endoscopic examinations were more commonly performed in the older group (p = 0.010), which had a high positive predictive value (88.3%). More patients recovered from CDI without specific antibiotic treatment in the younger group than in the older group (p < 0.001). Although advancing age is an important risk factor for CDI, the clinical features of younger patients are similar to those of the older patient population.

Septic Nonunions of Lower Limb Long Bones

We report 3 clinical cases of septic nonunions of lower limb long bones in which the pathogenicity of Propionibacterium acnes was retained after several weeks of poor outcome. The patients had fractures that were treated by internal fixation, without initially suspected infection. The diagnosis of delayed union coincided with the onset of treatment. Support was performed in 2 steps, allowing for the collection of several deep samples that were referred for microbiological analysis. Molecular techniques for microbiological investigation were performed on perioperative samples and were not contributive. The detection of P acnes, which was identified after several days of incubation, prompted us to consider the role of this bacterium. The presence of P acnes is regularly interpreted as contamination of samples during collection or handling in the laboratory. A multidisciplinary decision to make the diagnosis of surgical site infection with P acnes and specific antibiotic treatment for several months led to consolidation in all the patients. The ability of bacteria of the genus Propionibacterium to cause insidious surgical site infections should not be underestimated, and more extensive sample incubation is essential to diagnose such infections.

Vertebral and Pulmonary Actinomycosis Mimicking Metastatic Lung Cancer

Actinomycosis of the spine with spinal cord compression is rare. Only 22 cases are reported in the literature. The authors describe a remarkable case of a large lesion leading to bony destruction and spinal cord compression in the cervicothoracic junction with a large intrathoracic extension, which was considered to be a metastatic pulmonary disease but turned out to be actinomycosis. A 55-year-old man presented with acute tetraparesis. Magnetic resonance imaging (MRI) and computed tomography (CT) imaging showed vertebral body collapse of T1 and partially C7 with spinal cord compression as well as a mass in the right upper lobe with multiple intrapulmonary nodules. Moreover, dorsal elements (laminae and spinous process) were also involved and partially destructed. Differential diagnosis favored metastatic pulmonary disease. Decompression surgery was performed by anterior corpectomy of T1, stabilization with an expandable titanium cage and additional anterior plate C7-T2. Histology revealed typical sulfur granules. Microbiology exams were positive for Actinobacillus actinomycetemcomitans. There was no proof of malignancy in thoracic biopsy in the late diagnostic work-up. To prevent instrumentation failure, an external immobilization (halo fixation) was applied until complete fusion was documented in CT during the postoperative course. After an 11-month course of ampicillin/sulbactam, there was complete resolution of the intrapulmonary and spinal pathology. Thoracic actinomycosis with spinal involvement is a rare disease. Therefore, diagnosis may be difficult. Surgical intervention, correct diagnosis, and specific long-term antibiotic treatment resulted in favorable outcome.

Syndrome de Guillain-Barré révélant une fièvre Q aiguë

IntroductionQ fever is a polymorphic disease, which can induce neurological disturbances. The central nervous system is mainly involved while peripheral neuropathies are rare with less than 15 cases reported in the literature. Case-reportWe report here a case of acute polyradiculoneuritis associated with acute Q fever, with favorable outcome after antibiotic and intravenous immunoglobulin therapies. ConclusionSerologic tests for Coxiella burnetii should be performed in case of unusual polyradiculoneuritis with fever, headache and neuro-ophthalmologic disorders, even when environmental exposure is lacking, because Q fever requires specific antibiotic treatment and serological follow-up.

C1-C2 Pott’s Disease, a Rare Location of Spine Tuberculosis

The authors report a new case of spine tuberculosis of C1-C2 occurred in a 58-year-old negative HIV patient that was responsible of inflammatory cervical pain with multidirectional stiffness and complicated by spastic quadriplegia. The diagnosis was made on the basis of presumptive elements, including cervical spinal CT scan, which showed atlan-to-axial subluxation (C1-C2) with destruction of the odontoid apophysis and lateral mass of the atlas and favorable evolution under specific antibiotic treatment with ethambutol, isoniazid, rifampicin, pyrazinamide and immobilization with brace cast, despite the absence of bacteriological and anatomo-pathological evidence of certainty. The evolution has been favorable, with the disappearance of cervical pain, progressive motor recovery and resumption of autonomy of walking.

Osteonecrosis maxilar asociada a bisfosfonatos e infección por Actinomyces

Bisphosphonate related osteonecrosis of the jaw (BRONJ) has raised considerable interest since its recent description. Its pathogenesis is not yet clarified; formerly it has been considered a non-infectious complication, but recent studies seem to implicate bacteria of the genus Actinomyces. The objective of this study is to analyze the cases of BRONJ in our institution. Review of medical records of patients diagnosed of BRONJ in the Maxillofacial Surgery Unit of our hospital. We have found 11 cases of BRONJ in our hospital: 4 women taking oral alendronate or risendronate for osteoporosis and 7 cancer patients treated with intravenous zolendronic acid. All of them showed bone invasion by bacteria of the genus Actinomyces. Nine patients underwent prolonged treatment with amoxicillin with favourable clinical outcome in all of them, but 3 died of their malignancy. By contrast, one patient with beta-lactamic allergy and irregular treatment with erythromycin and tetracycline had a chronic evolution of the lesions. There was no information for other patient. Actinomyces play an important role in the development of BRONJ and specific antibiotic treatment improves the prognosis of this process.

Propionibacterium acnes: an underestimated etiology in the pathogenesis of osteoarthritis?

Propionibacterium acnes is a common pathogen in infections after shoulder surgery. Recent reports found positive P acnes cultures in a high percentage of patients who had revision shoulder arthroplasty for "aseptic loosening" without any overt signs of infection. Isolation of P acnes is difficult, and by use of conventional microbiological protocols of 48-hour incubation, a considerable proportion of patients with possible P acnes infection may remain unidentified. We recently noted P acnes in shoulder joint cultures in patients undergoing primary shoulder replacement for glenohumeral arthropathy without any signs of infection. We collected aspirates and biopsy specimens from 55 consecutive patients with arthritic shoulders undergoing primary joint replacement and examined them for the presence of P acnes. Special measures were taken to ensure that the specimens were carefully taken from within the joint to reduce the risk of contamination to minimal. In 23 of 55 consecutive patients (41.8%) undergoing primary shoulder joint replacement, P acnes was found in the joint fluid and tissues taken before the insertion of the implants. All these patients were treated early postoperatively with pathogen-directed specific dual oral antibiotic treatment for 4 weeks. In none have any signs of infection developed. This finding of a high incidence of P acnes in joints before arthroplasty may suggest a role of P acnes in the pathogenesis of glenohumeral arthropathy. In addition, it raises the question of whether development of painful joint replacement later on and presumed aseptic loosening do, in fact, comprise an unrecognized low-grade infection that has been present since before the index operation.

Encephalitis in the Pediatric Population

1. Stephen J. Falchek, MD* 1. *Division of Pediatric Neurology, Alfred I. duPont Hospital for Children/Thomas Jefferson University, Wilmington, DE, and Philadelphia, PA. * Abbreviations: ADEM: : acute disseminated encephalomyelitis CEP: : California Encephalitis Project CNS: : central nervous system CPP: : cerebral perfusion pressure CSF: : cerebrospinal fluid HSV: : herpes simplex virus IVIG: : intravenous immune globulin MS: : multiple sclerosis PCR: : polymerase chain reaction WNV: : West Nile virus Management of encephalitis, which can be fatal, requires understanding of a broad range of causative agents, pathophysiologic mechanisms, clinical syndromes, and outcomes. After completing this article, readers should be able to: 1. Know the many causes of encephalitis, including infectious, parainfectious, and noninfectious disorders. 2. Recognize the clinical features of encephalitis. 3. Be able to conduct a diagnostic investigation of a patient with encephalitis by using clinical and laboratory criteria. 4. Know the anticipated clinical course of different types of encephalitis. 5. Be familiar with the modalities used to treat encephalitis. 6. Understand the factors that influence the outcome in a patient who has encephalitis. The broad definition of the term “encephalitis,” that is, inflammation of the brain , necessitates acknowledgment of the enormous inclusivity of the topic. The most common interpretation of the term implies a direct invasion of the brain by an infectious pathogen, most commonly, viral, fungal, or parasitic. The topic also includes examples of meningitis mediated by bacteria or other agents, which can produce extrameningeal symptoms such as lethargy or seizures, in which case, the combined term “meningoencephalitis” is used. There are also many examples of encephalitis not due to direct central nervous system (CNS) infections. Inflammatory processes due to an acute or chronic illness can result in an acute immune-mediated encephalitis, such as acute disseminated encephalomyelitis (ADEM), lupus cerebritis, and paraneoplastic syndromes. Agents or conditions that produce slowly progressive CNS symptoms, such as tertiary syphilis or “slow viruses” (the prion protein encephalopathies), also are considered examples of encephalitis. Table 1 lists only a limited number of the many pathogens and pathologic conditions that can cause either acute or subacute encephalitis. In this discussion, …

Unusual presentation of an anterior sacral meningocele: magnetic resonance imaging, multidetector computed tomography, and fistulography findings of bacterial meningitis secondary to a rectothecal fistula

An anterior sacral meningocele, a rare congenital anomaly, manifested in a previously healthy 44-year-old woman with findings of meningitis, including headache, vomiting, unconsciousness, and fever. Nontraumatic pneumocephalus, tetraventricular hydrocephalus, fluid-fluid level at the lateral ventricles, and pial enhancement were observed on multidetector computed tomography. A ventricular drainage catheter was placed to decompress the hydrocephalus, and drainage was performed urgently. Escherichia coli was isolated from the drainage material. Whole-spine magnetic resonance imaging and fistulography were undertaken on the third day after admission to evaluate for anal and urinary incontinence and pareses of both upper and lower extremities. Spinal arachnoiditis, tethered cord, dysgenesis of the sacrum, and a rectothecal fistula were demonstrated. Specific antibiotic treatment and surgery for fistula tract excision were performed.

Pulmonary hemorrhage in horses seropositive to leptospirosis

The aim of this study was to verify the occurrence and severity of pulmonary hemorrhage (PH) in horses seropositive or not to leptospirosis. A total of 84 training horses were tested for anti-Leptospira antibodies and submitted to endoscopy of the upper airways 30-60 minutes after exercise. Forty-nine (46.4%) horses were seropositive (titer&gt;100) to serovar Copenhageni. Seventeen horses (20.2%) presented PH in different grades, significantly more commonly observed in seropositives (34.7%) than seronegatives (8.6%) (p&lt;0.05), and also more severe in the first. Additionally, a seropositive horse is 4.26 times more likely (OR) to present PH than a seronegative one. Fifteen days after specific antibiotic treatment for leptospirosis a significant improvement in grade of hemorrhage was observed. Therefore it is suggested that leptospirosis may potentiate the severity of PH and that specific antibiotic treatment directed towards leptospirosis may help to control the disease.

Múltiples abscesos cerebrales por Listeria monocitogenes en un paciente con infección por el virus de inmunodeficiencia humana, primer caso descrito en Colombia

The manifestations of Listeria monocytogenes central nervous system infection are wide, ranging from meningitis to cerebral abscesses. Those are clinically indistinguishable from other forms of cerebral abscesses. We are describing a HIV positive woman who presented with generalized tonicclonic seizures, progressive alter mental status, evidence of lymphocytic pleocytosis and multiple hypodense lesions that enhanced with contrastae on imaging studies (CT and MRI) Listeria monocytogenes was isolated of cefaloraquid liquid cultures. After a specific antibiotic treatment regimen associated with steroids, improved neurological symptoms and concomitant documented a progressive decrease until disappearance of the lesions in the CNS imaging follow. Listeria monocytogenes is a cause of brain abscesses in immunosuppressed patients especially HIV patients without antiretroviral therapy and without prophylaxis with trimethoprim / sulfamethoxazole.

Mycoplasma pneumonia Infection: A Possible Trigger for Immune Thrombocytopenia

Mycoplasma pneumonia (M. pneumonia) is usually not considered among the several pathogens that induce immune thrombocytopenia (ITP). We report a child with a clinical diagnosis of severe ITP that was associated with M. pneumonia pneumonia, and review the few cases described in the English literature. We suggest that thrombocytopenia associated with M. pneumonia infection may constitute a subset of ITP, although unlike ITP it occurs concomitantly with the infection and tends to be more severe than "classic" ITP. We recommend that prompt specific antibiotic and immune modulating treatment should be initiated in appropriate clinical settings.

Factors Affecting the Cost Effectiveness of Antibiotics

In an era of spiraling health care costs and limited resources, policy makers and health care payers are concerned about the cost effectiveness of antibiotics. The aim of this study is to draw on published economic evaluations with a view to identify and illustrate the factors affecting the cost effectiveness of antibiotic treatment of bacterial infections. The findings indicate that the cost effectiveness of antibiotics is influenced by factors relating to the characteristics and the use of antibiotics (i.e., diagnosis, comparative costs and comparative effectiveness, resistance, patient compliance with treatment, and treatment failure) and by external factors (i.e., funding source, clinical pharmacy interventions, and guideline implementation interventions). Physicians need to take into account these factors when prescribing an antibiotic and assess whether a specific antibiotic treatment adds sufficient value to justify its costs.

Long target droplet polymerase chain reaction with a microfluidic device for high-throughput detection of pathogenic bacteria at clinical sensitivity

In this article we present a long target droplet polymerase chain reaction (PCR) microsystem for the amplification of the 16S ribosomal RNA gene. It is used for detecting Gram-positive and Gram-negative pathogens at high-throughput and is optimised for downstream species identification. The miniaturised device consists of three heating plates for denaturation, annealing and extension arranged to form a triangular prism. Around this prism a fluoropolymeric tubing is coiled, which represents the reactor. The source DNA was thermally isolated from bacterial cells without any purification, which proved the robustness of the system. Long target sequences up to 1.3 kbp from Staphylococcus aureus, Escherichia coli and Pseudomonas aeruginosa have successfully been amplified, which is crucial for the successive species classification with DNA microarrays at high accuracy. In addition to the kilobase amplicon, detection limits down to DNA concentrations equivalent to 10(2) bacterial cells per reaction were achieved, which qualifies the microfluidic device for clinical applications. PCR efficiency could be increased up to 2-fold and the total processing time was accelerated 3-fold in comparison to a conventional thermocycler. Besides this speed-up, the device operates in continuous mode with consecutive droplets, offering a maximal throughput of 80 samples per hour in a single reactor. Therefore we have overcome the trade-off between target length, sensitivity and throughput, existing in present literature. This qualifies the device for the application in species identification by PCR and microarray technology with high sample numbers. Moreover early diagnosis of infectious diseases can be implemented, allowing immediate species specific antibiotic treatment. Finally this can improve patient convalescence significantly.

Short-course treatment in neurobrucellosis: A study in Iran

Neurobrucellosis is a rare neurological complication of brucellosis. This report describes 19 patients of neurobrucellosis and they accounted for 8% of all cases of brucellosis admitted to Shiraz University Hospitals over a period of eight years. Headache, fever, fatigue, drowsiness and neck stiffness were the common clinical features. Cerebrospinal fluid (CSF) showed pleocytosis in 100%, elevated protein levels in 89% and low glucose level in 47% of the patients. All the patients improved with specific antibiotic treatment. Of the 19 patients, 10 (52.5%) patients received treatment for 8 to 28 weeks. Duration of antibiotic treatment was: 8-14 weeks in 8 (42%) patients; 24-28 weeks in 2 (10.5%) patients; 6 months in 7 (37%) patients; 12 months in 1 (5.3%) patient; and 18 months in 1 (5.3%) patient. Clinicians in endemic areas should consider the likelihood of neurobrucellosis in patients with unexplained neurological and psychiatric symptoms.

Algorithm for the management of antibiotic prophylaxis in onychocryptosis surgery

Background Antibiotic prophylaxis in nail surgery is not clearly established, and there is scant scientific evidence regarding the need for its use in preventing surgical site infection, hematogenous total joint infection, and infective endocarditis. Objectives To propose an algorithm based on the evidence for the management of antibiotic prophylaxis in onychocryptosis surgery. Methods A literature review was performed in Medline, Pubmed, Cochrane database and Scopus and recent prospective studies were examined. The most-current authoritative guidelines together with new classification system of the pathology have been taken into account. Results In non-risk patients with onychocryptosis stage II or III phenol technique can be used without the need for antibiotics. In stages IV and V, specific antibiotic treatment should be administered before surgery together with partial ablation of nail until the infection is resolved and the process remits to stage II or III. In the case of long-developing onychocryptosis, osteomyelitis should be ruled out, and specific antibiotic treatment besides the preoperative dose should be administered. In high-risk cardiac patients with infective onychocryptosis, the need for prophylaxis for bacterial endocarditis should be considered. Conclusion Current evidence does not support the use of preoperative antibiotic prophylaxis in onychocrytosis surgery except in special patients with infective onychocryptosis.

Manifestaciones osteoarticulares de endocarditis

Infective endocarditis is a fatal disease unless specifically treated. This entity must be suspected immediately in all patients with fever or sepsis and heart murmur and an echocardiogram should be performed to confirm the diagnosis.In a few case series, a significant proportion of patients diagnosed with infective endocarditis showed osteoarticular involvement, which preceded, sometimes by months, the onset of specific symptoms of endocarditis.Even when no specific musculoskeletal symptoms associated with endocarditis are found, these symptoms must be kept in mind and infective endocarditis should be suspected when musculoskeletal manifestations are the presenting symptom, because of the potentially dire consequences of delaying specific antibiotic treatment.

Méningoencéphalite à Rickettsia conorii chez un nourrisson

Mediterranean spotted fever is an infectious disease due to Rickettsia conori, endemic in the Mediterranean basin. It is usually considered to be a benign disease; however, severe systemic manifestations have been reported in which neurological involvement occurs. These complications are rare in children. We report a case of a 14-month-old boy, who was hospitalized for meningoencephalitis after seven days of high fever and maculopapular rash. On clinical observation there were generalized maculopapular elements and an inoculation eschar tache noire at the right ear. The diagnosis of Mediterranean spotted fever was established by epidemiological and clinical features and was confirmed by elevated IgM antibody titres against R.conorii by indirect immunofluorescence assay. Despite treatment with macrolides and corticosteroids, severe neurological sequelae have remained including decreased vision and epileptic seizures. The physiopathology of Mediterranean spotted fever includes diffuse vasculitis with endothelial injury. Early diagnosis and specific antibiotic treatment may reduce the risk of complications.