Successful Treatment Of Infection Research Articles

Handmade spacers for two-stage exchange at the hip.

Two-stage exchange with implantation of atemporary spacer is the gold standard treatment for chronic periprosthetic joint infection of the hip. This article describes asimple and safe technique for handmade spacers at the hip. Periprosthetic joint infection of the hip. Septic arthritis of the native joint. Known allergy against components of polymethylmethacrylate bone cements. Inadequate compliance for two-stage exchange. Patient unfit to undergo two-stage exchange. Bony defect situation at the acetabulum impeding stable reduction of the spacer. Bone loss at the femur jeopardizing stable fixation of the stem. Soft tissue damage with need for plastic temporary vacuum-assisted wound closure (VAC) therapy. Tailoring bone cement with antibiotics. Preparation of ametal endoskeleton. Molding of spacer stem and head by hand. Customizing spacer off-sets to bony anatomy and soft tissue tension. Implantation assuring rotational stability at the femur with abone cement collar. Confirmation of correct position by intraoperative radiography. Restricted weight-bearing. Range of motion as possible. Reimplantation after successful treatment of infection.

Handmade articulating spacer for two-stage exchange at the knee.

Two-stage exchange with implantation of atemporary spacer is considered gold standard treatment for chronic periprosthetic joint infection of the knee. This article describes asimple and safe technique for handmade articulating spacers at the knee. Chronic or relapsing periprosthetic joint infection of the knee. Known allergy against components of polymethylmethacrylate (PMMA) bone cements or admixed antibiotics. Inadequate compliance for two-stage exchange. Patient not able to undergo two-stage exchange. Bony defect situation at the tibia or femur leading to collateral ligament insufficiency. Soft tissue damage with need for plastic temporary vacuum-assisted wound closure (VAC) therapy. Removal of the prosthesis, thorough debridement of necrotic and granulation tissue, tailoring bone cement with antibiotics. Preparation of atibial and femoral stem. Customizing the tibial and femoral articulating spacer components to bony anatomy and soft tissue tension. Confirmation of correct position by intraoperative radiography. Protection of the spacer with an external brace. Restricted weight-bearing. Passive range of motion as possible. Intravenous-followed by oral antibiotics. Reimplantation after successful treatment of infection.

Chinese expert consensus on diagnosis and treatment of infection after fracture fixation

Currently, accurate diagnosis and successful treatment of infection after fracture fixation (IAFF) still impose great challenges. According to the onset of infection symptoms after implantation, IAFF is classified as early infection (<2 weeks), delayed infection (2∼10 weeks) and late infection (>10 weeks). Confirmation of IAFF should be supported by histopathological tests of intraoperative specimens which confirm infection, cultures from at least two suspected infection sites which reveal the same pathogen, a definite sinus or fistula which connects directly the bone or the implant, and purulent drainage from the wound or presence of pus during surgery. Diagnosis of IAFF is built on comprehensive assessment of medical history, clinical signs and symptoms of the patient, and imaging and laboratory tests. The gold standard of diagnosis is histopathological tests. Treatment of IAFF consists of radical debridement, adequate irrigation, implant handling, systematic and local antibiotics, reconstruction of osseous and/or soft tissue defects, and functional rehabilitation of an affected limb. Early accurate diagnosis and appropriate treatment of IAFF play a key role in increasing the cure rate, reducing infection recurrence and disability risk, restoring limb function and improving quality of life of the patient.

23.2 Clinical Management of Pediatric Acute-Onset Neuropsychiatric Syndrome: Treatment and Prevention of Infections

Although the trigger of each initial onset or flare of pediatric acute-onset neuropsychiatric syndrome (PANS) is not known, infections frequently precede PANS flares and successful treatment of infection often resolves a flare or improves the clinical course of PANS. This presentation reviews expert consensus guidelines for the clinical management of infection in patients with PANS.

Unilateral inline replacement of infected aortofemoral graft limb with femoral vein

ObjectiveAortic graft infection remains a formidable challenge for the vascular surgeon. Traditionally, reconstruction with a neoaortoiliac system (NAIS) involves removal of the entire synthetic graft with in situ reconstruction using femoral vein. Whereas the NAIS procedure is durable with excellent graft patency and a low reinfection rate, it can take up to 10 hours and result in a high perioperative complication rate with significant mortality. Not infrequently, the infection is limited to a single limb. In addition, the patient may be too frail to tolerate aortic clamping for a complete graft excision. Under such circumstances, complete excision of the aortofemoral bypass graft (AFBG) may not be indicated. It is hypothesized that local control of infection and limited reconstruction using femoral vein may be acceptable. The objective of this study was to examine the outcomes of all patients who underwent partial AFBG resection and in situ reconstruction with femoral vein. MethodsA retrospective review of all AFBG infections from 2003 to 2015 treated at a tertiary care facility was undertaken. Patients who underwent unilateral partial graft excision with inline reconstruction using femoral vein at the distal (femoral) anastomosis were included. Complete excisions with bilateral revascularizations using any conduit or any extra-anatomic reconstructions were excluded. The primary end point was successful treatment of infection. Secondary end points were procedure-related mortality, graft patency, and perioperative complications. ResultsDuring a 12-year period, partial graft excision with bypass using the femoral vein was performed in 21 patients (24 limbs). Mean age was 61 ± 12 years. There were 13 men and 8 women. Mean follow-up was 53 ± 27 months. Successful treatment was achieved in 19 of 21 patients. The two treatment failures were due to persistent infection. One of these patients declined complete graft excision and is receiving lifelong suppressive antibiotic therapy. The other patient underwent complete graft excision and an NAIS reconstruction. There were no perioperative or procedure-related deaths. There were no major amputations, and primary graft patency was 92% at 72 months. The most common AFBG culture isolate was Staphylococcus species. Approximately one-third of cultures did not yield any growth. Patients underwent anywhere from 1 to 12 weeks of combined intravenous and oral antibiotic therapy. ConclusionsThis limited series demonstrates excellent graft patency with a low persistent infection rate. Thus, in patients with localized graft infection, partial excision with preservation of the proximal synthetic graft is an acceptable alternative when patient factors preclude complete graft excision.

Effect of non-steroidal anti-inflammatory drugs on biological properties of Acanthamoeba castellanii belonging to the T4 genotype

Non-steroidal anti-inflammatory drug, Diclofenac, targeting COX have shown promise in the treatment of Acanthamoeba keratitis, but the underlying mechanisms remain unknown. Using various NSAIDs, Diclofenac sodium, Indomethacin, and Acetaminophen, here we determined the effects of NSAIDs on the biological properties of Acanthamoeba castellanii belonging to the T4 genotype. Using amoebicidal assays, the results revealed that Diclofenac sodium, and Indomethacin affected growth of A. castellanii. In contrast, none of the compounds tested had any effect on the viability of A. castellanii. Importantly, all NSAIDs tested abolished A. castellanii encystation. This is a significant finding as the ability of amoebae to transform into the dormant cyst form presents a significant challenge in the successful treatment of infection. The NSAIDs inhibit production of cyclo-oxegenase, which regulates the synthesis of prostaglandins suggesting that cyclooxygenases (COX-1 and COX-2) and prostaglandins play significant role(s) in Acanthamoeba biology. As NSAIDs are routinely used in the clinical practice, these findings may help design improved preventative strategies and/or of therapeutic value to improve prognosis, when used in combination with other anti-amoebic drugs.

Increased Long‐Term Mortality in Patients with Cardiovascular Implantable Electronic Device Infections

Device infection is associated with increased mortality in patients receiving cardiovascular implantable electronic device (CIED) therapy. However, long-term mortality associated with CIED infections has not been systematically analyzed in larger studies. This study sought to determine the long-term mortality associated with CIED infection in a large cohort of Medicare beneficiaries. We used a retrospective study design to analyze 3-year mortality in 200,219 Medicare fee-for-service patients admitted for CIED generator implantation, replacement, or revision between January 1, 2007 and December 31, 2007. Multivariate analysis adjusting for age, sex, race, and 28 comorbidities was performed to determine the relative risk (RR) of death in the 12 quarters following CIED infection. Patients with CIED infection, compared to device recipients without infection, had increased mortality that persisted for at least 3 years after the admission quarter for all device types: pacemakers (PMs: 53.8% vs 33%; P < 0.001), implantable cardioverter defibrillator (ICD: 47.7% vs 31.6%; P < 0.001), and cardiac resynchronization therapy-defibrillator (CRT-D: 50.8% vs 36.5%; P < 0.001). After adjusting for patient demographics and comorbidities, significantly increased RR of death following CIED infection persisted for at least 3 years following PM infection, and for at least 2 years with single- and dual-chamber ICD infection. CIED recipients who develop device infection have increased, device-dependent, long-term mortality even after successful treatment of infection. The etiology of this persistent increased risk of death associated with CIED infection is unknown and merits further investigation.

The treatment of diabetic foot infections

Successful treatment of infection in the feet of patients with diabetes mellitus remains a challenge. Although the diagnosis of infection remains a clinical decision, presentation in feet rendered insensate from diabetic neuropathy plus co-existing vascular insufficiency means presentation is often atypical. Wounds frequently yield polymicrobial growth and differentiating commensal from pathogenic organisms can be difficult; isolates from diabetic foot wounds are often multidrug resistant. Affected patients often have many other co-morbidities, which not only affect the choice of appropriate antimicrobial regimen but also impede healing. Further, much contention surrounds the management of osteomyelitis, with the merits and role of surgery still undecided. In this review we briefly consider the epidemiology and pathogenesis of diabetic foot disease, before discussing emerging best microbiological practice and how this fits with the multidisciplinary approach required to tackle this difficult clinical problem.

Serum creatinine and bilirubin predict renal failure and mortality in patients with spontaneous bacterial peritonitis: a retrospective study

Patients with spontaneous bacterial peritonitis (SBP) are at a high risk for renal failure and death despite successful treatment of infection. Intravenous (IV) albumin administration combined with antibiotic treatment has been shown to significantly decrease these risks. Clinical evidence is lacking on which patients are appropriate candidates for albumin treatment. To retrospectively analyse the usefulness of serum creatinine and bilirubin levels in predicting renal failure and mortality of patients hospitalized for SBP. Between March 1995 and September 1998, 127 cirrhotic patients with SBP who had not received plasma expansion were evaluated. Eighty-one patients (64%) were classified as having a high risk for renal failure and mortality (serum bilirubin >4 mg/dl or serum creatinine >1 mg/dl) and 46 (36%) as having a low risk. At admission, 36.3% of all patients presented renal failure. Mortality during their hospitalization was 23% among those with a high risk and 6.5% among those with a low risk (P=0.01). Renal failure occurred in 23% of the high-risk patients, compared with 2.6% of the low-risk patients (P=0.006). The presence of hyponatraemia was significantly associated with higher mortality and renal failure in the high-risk group. Our retrospective review of patients with SBP suggests that serum bilirubin levels >4 mg and serum creatinine levels >1 mg/dl at the time of diagnosis represent significant risk factors for the clinical outcomes of patients with SBP. Patients without these risk factors may have a very low likelihood of death or renal failure.

Effects of molgramostim, filgrastim and lenograstim in the treatment of myelokathexis

Myelokathexis is a very rare form of chronic hereditary neutropenia resulting from impaired neutrophil releasing mechanism in the bone marrow. The recombinant human granulocyte-macrophage (molgramostim) and granulocyte (filgrastim, lenograstim) colony stimulating factors release the mature granulocytes from the bone marrow. We describe a 43-year-old woman suffering from myelokathexis, with the absolute neutrophil count ranging between 0.03 and 1.35 × 109/L. In the period before the introduction of cytokines, the patient had more than 80 major infectious episodes. Since 1991, infections in this patient have been treated with cytokines, given in conjunction with antibiotics. Initially, she received molgramostim in a daily dose of 5 μg/kg subcutaneously, which stimulated the release of granulocytes from her bone marrow, thereby allowing successful treatment of infection. After the development of hypersensitivity, molgramostim was substituted with filgrastim. Finally, lenograstim was given a trial. With all three cytokines, the patient's neutrophil count always attained normal values already 4 hours after subcutaneous application of the drug in a dose of 5 μg/kg, the highest neutrophil levels were measured at 24 hours post-injection, and the neutrophil count was again close to the baseline value 72 hours after the treatment. A slight neutropenia was present 48 hours after the application of filgrastim. We believe that all three cytokines are equally effective in increasing the neutrophil count in venous blood of patients with myelokathexis.

Infection and hemostasis in decompensated cirrhosis: a prospective study using thrombelastography.

Bacterial infections are common complications in decompensated cirrhosis, but their relationship with hemostasis has not been studied. We prospectively assessed whether infection affects hemostasis in cirrhosis using routine hemostasis tests and thrombelastography (TEG), a global test of hemostatic function. Eighty-four cirrhotic patients (Child-Pugh B: 26; C: 58) without overt bleeding or blood-product transfusion were prospectively evaluated with routine hemostasis tests and TEG on admission and/or the first day with signs of infection and 5 days later. There were 30 patients with infection; 15 had infection on admission, and 15 developed infection in hospital. In the patients who developed infection in hospital, there was a significant deterioration in all routine hemostasis tests except platelet count (PLT) and in all TEG parameters, on the first day of infection compared with 7 +/- 3 days previously. The same parameters significantly improved from the first day of infection to day 5 and after (P <.02) only in the 22 patients whose infection resolved, while the r, k, and alpha TEG parameters significantly worsened in the 8 patients with persistent infection. In those who developed infection in hospital and were cured (n = 11), the 5-day parameters did not differ from their preinfection values. In conclusion, bacterial infections frequently impair hemostasis in decompensated cirrhotic patients. Successful treatment of infection usually restores hemostasis parameters to preinfection levels in 5 days. Thus, infection may have a role in the bleeding diathesis of cirrhosis.

Migratory Polyarthritis Associated withPlesiomonas shigelloidesInfection

Migratory polyarthritis was observed in a child with Plesiomonas shigelloides infection of the gastrointestinal tract. All symptoms and signs of arthritis resolved following successful treatment of infection with the appropriate antibiotic. Plesiomonas shigelloides should be added to the list of microbial agents associated with polyarthritis.

Antibiotics in Patients With Neutropenia

Successful treatment of infection in patients with neutropenia is usually possible if several principles are followed. The most important of these is prompt administration of antibiotic therapy, even if the patient has no symptoms or signs of infection other than fever. Most infections are caused by gram-negative bacilli, but even "nonpathogenic" organisms can cause serious infections. Antibiotic combinations should be selected that provide broad-spectrum coverage and are active against the most prevalent organisms in the hospital. Aminoglycosides are often ineffective in patients with persistent neutropenia and should not be used alone. A variety of effective combination regimens are available for initial therapy of presumed or proved infection in patients with neutropenia, including a beta-lactam plus an aminoglycoside or two beta-lactam antibiotics.

Therapy for Septic Arthritis

The usefulness of the results of serial cultures of synovial fluid in assessing the response to medical therapy of acute bacterial joint infections was examined. A five-year retrospective survey disclosed 32 synovial fluid culture-proved cases of septic arthritis in adults. Thirteen of the patients had well-documented evidence of (1) duration of articular symptoms (presumably reflecting the presence of infection) and (2) subsequent time required to sterilize the synovial fluids (as determined by serial synovial fluid cultures). We found a positive correlation between duration of symptoms and length of time during which serial cultures of synovial fluids remained positive after initiation of treatment. In the seven patients with good outcome, cultures remained positive for 2.4+/-1.9 days, as opposed to 8.2+/-2.4 days in the six patients with poor results. The time required to sterilize the synovial fluid appears to be a reliable indicator of response to therapy and an accurate predictor of outcome. Our data show that the rapidity in achieving synovial fluid sterility is of paramount importance in the successful treatment of infection, preservation of articular integrity, and restoration of joint function.

Therapy for septic arthritis

The usefulness of the results of serial cultures of synovial fluid in assessing the response to medical therapy of acute bacterial joint infections was examined. A five-year retrospective survey disclosed 32 synovial fluid culture-proved cases of septic arthritis in adults. Thirteen of the patients had well-documented evidence of (1) duration of articular symptoms (presumably reflecting the presence of infection) and (2) subsequent time required to sterilize the synovial fluids (as determined by serial synovial fluid cultures). We found a positive correlation between duration of symptoms and length of time during which serial cultures of synovial fluids remained positive after initiation of treatment. In the seven patients with good outcome, cultures remained positive for 2.4±1.9 days, as opposed to 8.2±2.4 days in the six patients with poor results. The time required to sterilize the synovial fluid appears to be a reliable indicator of response to therapy and an accurate predictor of outcome. Our data show that the rapidity in achieving synovial fluid sterility is of paramount importance in the successful treatment of infection, preservation of articular integrity, and restoration of joint function. (<i>JAMA</i>1982;247:797-800)

INTERNAL FIXATION OF FRACTURES OF THE THIRD PHALANX IN THREE HORSES

The technique of internal fixation of intra-articular fractures of the third phalanx using lag screw interfragmentary compression is described. Three cases are discussed and the successful treatment of infection and osteomyelitis described in one of them. Despite this potential complication internal fixation offers a better prognosis and also a more rapid return to work than non-operative treatments.