Suppressive Antibiotic Therapy Research Articles

849. Reduced CIED Infections with an Antibacterial Envelope: Microbiologic Analysis of the WRAP-IT Study

BackgroundCardiovascular implantable electronic device (CIED) infections are associated with significant morbidity, mortality, and cost. There is limited evidence on antibiotic prophylactic strategies to prevent CIED infection. Recently, the TYRX Envelope, which elutes a combination of rifampin and minocycline for a minimum of 7 days, was shown to significantly reduce major CIED infections in the WRAP-IT trial. We sought to characterize the pathogens among patients who experienced an infection in the current era.MethodsAll patients undergoing CIED replacement, upgrade, revision, or de novo cardiac resynchronization therapy (CRT-D) received standard of care antibiotic prophylaxis and were randomized 1:1 to receive TYRX or not. The primary endpoint was major CIED infection within 12 months of the procedure. Major infection was defined as an infection resulting in (1) system extraction or revision, (2) long-term suppressive antibiotic therapy, or (3) death. Data were analyzed using the Cox proportional hazards regression model.ResultsA total of 6,983 patients were randomized worldwide with 3,495 randomized to receive an envelope and 3,488 randomized to the control. At 12 months, 25 major infections (0.7%) were observed in the envelope group and 42 major infections (1.2%) in the control group, resulting in a 40% reduction of major infections (HR: 0.60, 95% CI: 0.36–0.98, P = 0.04). Of 63 infections assayed, causative pathogens were identified in 36 infections whereas cultures were negative in 27 cases. Staphylococcus species (n = 22) were the predominate pathogens and a 53% reduction was observed with the use of TYRX (Figure 1). Moreover, there was only 1 CIED pocket infection with Staphylococcus species in the envelope group compared with 14 pocket infections in the control group. A comparison of timing of infection in the envelope group showed the presence of 11 endocarditis/bacteremia infections at 103 ± 84 days compared with 14 pocket infections presenting at 70 ± 78 days from the procedure.ConclusionIn this large randomized trial, the use of the TYRX Envelope containing rifampin and minocycline resulted in a significant reduction of major CIED infections and was effective against staphylococcal species, which are the predominant cause of pocket infections. Disclosures All Authors: No reported Disclosures.

Prolonged suppressive antibiotic therapy is successful in the management of prosthetic joint infection.

Prosthetic joint infection (PJI) remains one of the major challenges facing orthopaedic surgeons. There is a paucity of evidence on non-operative management of PJI. We present the results of prolonged antibiotic suppression therapy (PSAT) in PJI from a single centre. A retrospective study was performed. Twenty-six patients were included. Two patients were excluded due to the lack of follow-up data. Failure was defined as admission for sepsis from the joint or amputation. Average age was 72years (range 35-93). Mean Charlson co-morbidity index was 4.3. Mean follow-up was 3.2years (range 1.3-5.7). Staphylococcal species were isolated in 11 cases (44%) (MRSA 1, MSSA 5, Staph. epidermidis 4 and Staph Pasteuri 1). Other bacteria included E. Coli (2), Streptococci spp. (3), Propionebacterium acnes (1) and Pseudomonas aeruginosa (1). Four cases were polymicrobial infection (16%), and no organisms were identified in two cases (8%). Candida albicans was identified in one case. All cases of bacterial infection were treated with prolonged oral doxycycline or amoxicillin. Twenty patients (80%) received 6weeks of intravenous antibiotics prior to commencing prolonged oral antibiotics. Two patients experienced persistent symptoms and required amputation (both TKA). Two patients experienced sepsis but were treated successfully with IV antibiotics alone. The success rate of PSAT was 84% (21/25) successful at an average 3.2-year follow-up. Prolonged suppressive antibiotic therapy is a viable option for the management of PJI with a low incidence of complications.

Suppressive antibiotic therapy in prosthetic joint infections: a multicentre cohort study

ObjectivesThe aim was to describe the effectiveness of suppressive antibiotic treatment (SAT) in routine clinical practice when used in situations in which removal of a prosthetic implant is considered essential for the eradication of an infection, and it cannot be performed. MethodsThis was a descriptive retrospective and multicentre cohort study of prosthetic joint infection (PJI) cases managed with SAT. SAT was considered to have failed if a fistula appeared or persisted, if debridement was necessary, if the prosthesis was removed due to persistence of the infection or if uncontrolled symptoms were present. ResultsIn total, 302 patients were analysed. Two hundred and three of these patients (67.2%) received monotherapy. The most commonly used drugs were tetracyclines (39.7% of patients) (120/302) and cotrimoxazole (35.4% of patients) (107/302). SAT was considered successful in 58.6% (177/302) of the patients (median time administered, 36.5 months; IQR 20.75–59.25). Infection was controlled in 50% of patients at 5 years according to Kaplan–Meier analysis. Resistance development was documented in 15 of 65 (23.1%) of the microbiologically documented cases. SAT failure was associated with age <70 years (sub-hazard ratio (SHR) 1.61, 95% CI 1.1–2.33), aetiology other than Gram-positive cocci (SHR 1.56, 95% CI 1.09–2.27) and location of the prosthesis in the upper limb (SHR 2.4, 95% CI 1.5–3.84). SAT suspension was necessary due to adverse effects in 17 of 302 patients (5.6%). ConclusionsSAT offers acceptable results for patients with PJI when surgical treatment is not performed or when it fails to eradicate the infection.

Timing of implant-removal in late acute periprosthetic joint infection: A multicenter observational study

ObjectivesWe evaluated the treatment outcome in late acute (LA) periprosthetic joint infections (PJI) treated with debridement and implant retention (DAIR) versus implant removal. MethodsIn a large multicenter study, LA PJIs of the hip and knee were retrospectively evaluated. Failure was defined as: PJI related death, prosthesis removal or the need for suppressive antibiotic therapy. LA PJI was defined as acute symptoms <3 weeks in patients more than 3 months after the index surgery and with a history of normal joint function. Results445 patients were included, comprising 340 cases treated with DAIR and 105 cases treated with implant removal (19% one-stage revision (n = 20), 74.3% two-stage revision (n = 78) and 6.7% definitive implant removal (n = 7). Overall failure in patients treated with DAIR was 45.0% (153/340) compared to 24.8% (26/105) for implant removal (p < 0.001). Difference in failure rate remained after 1:1 propensity-score matching. A preoperative CRIME80-score ≥3 (OR 2.9), PJI caused by S. aureus (OR 1.8) and implant retention (OR 3.1) were independent predictors for failure in the multivariate analysis. ConclusionDAIR is a viable surgical treatment for most patients with LA PJI, but implant removal should be considered in a subset of patients, especially in those with a CRIME80-score ≥3.

Successful long-term antibiotic suppressive therapy in a case of prosthetic valve endocarditis and a case of extensive aortic and subclavian graft infection

IntroductionThe indication for surgical valve replacement in cases of infective endocarditis is well defined in current guidelines. However, some patients are not fit or willing to undergo major surgical procedures. Interestingly, to the best of our knowledge, there is scarce information in the literature on how to deal with such cases and what might be the outcome.Case reportWe present two complicated cases of prosthetic infective endocarditis with definite indication for replacement of involved foreign material, who were treated successfully with long-term suppressive antibiotic therapy.ConclusionThese two cases demonstrate that individualized long-term antibiotic suppressive therapy might be effective in selected patients with complicated PVE unfit or unwilling to undergo high-risk cardiothoracic surgical interventions.

Multiflora and Gram-Negative Microorganisms Predominate in Infections Affecting Pelvic Endoprostheses Following Tumor Resection.

Periprosthetic infections after pelvic reconstruction are common, with reported rates ranging from 11% to 53%. Management of these infections is troublesome, as they commonly necessitate multiple surgical interventions and implant removal. The epidemiology and outcomes of these infections are largely unknown. The aim of this study was to analyze the causative microorganisms and the clinical outcome of treatment in a series of patients with pelvic endoprostheses affected by infection following tumor resection. In this retrospective, multicenter cohort study, we identified all patients who developed an infection after endoprosthetic reconstruction in periacetabular tumor resection, between 2003 and 2017. The microorganisms that were isolated during the first debridement were recorded, as were the number of reoperations for ongoing infection, the antimicrobial treatment strategy, and the outcome of treatment. In a series of 70 patients who underwent pelvic endoprosthetic reconstruction, 18 (26%) developed an infection. The type of pelvic resection according to the Enneking-Dunham classification was type P2-3 in 14 (78%) of these patients and type P2 in 4 (22%). Median follow-up was 66 months. Fourteen (78%) of the 18 patients with infection had a polymicrobial infection. Enterobacteriaceae were identified on culture for 12 (67%). Of a total 42 times that a microorganism was isolated, the identified pathogen was gram-negative in 26 instances (62%). Microorganisms associated with intestinal flora were identified 32 times (76%). At the time of latest follow-up, 9 (50%) of the patients had the original implant in situ. Of these, 2 had a fistula and another 2 were receiving suppressive antibiotic therapy. In the remaining 9 (50%) of the patients, the original implant had been removed. At the time of final follow-up, 3 of these had a second implant in situ. The remaining 6 patients had undergone no secondary reconstruction. Infections that affect pelvic endoprostheses are predominantly polymicrobial and caused by gram-negative microorganisms, and may be associated with intestinal flora. This differs fundamentally from mono-bacterial gram-positive causes of conventional periprosthetic joint infections and may indicate a different pathogenesis. Our results suggest that prophylaxis and empiric treatment may need to be re-evaluated. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Subcutaneous suppressive antibiotic therapy for bone and joint infections: safety and outcome in a cohort of 10 patients.

Optimal treatment of prosthetic joint infection and chronic osteomyelitis consists of surgical removal of biofilm-embedded bacteria, followed by a 6-12 week course of antimicrobial therapy. However, when optimal surgery is not feasible, oral prolonged suppressive antibiotic therapy (PSAT) is recommended to prevent prosthesis loosening and/or relapse of infection. Since 2010, we have used infection salvage therapy using off-label subcutaneous (sc) injection of a β-lactam as PSAT for patients in whom oral PSAT is not possible. A single-centre prospective cohort study (2010-18) reporting treatment modalities, efficacy and safety in all patients receiving sc PSAT. NCT03403608. The 10 included patients (median age 79 years) had polymicrobial (n = 5) or MDR bacterial (n = 4) prosthetic joint infection (knee, n = 4; hip, n = 3) or chronic osteomyelitis (n = 3). After initial intensive therapy, seven patients received ertapenem, three patients received ceftriaxone and one patient received ceftazidime by sc injection (one patient received 8 days of ceftriaxone before receiving ertapenem). In one patient, sc PSAT failed with recurrent signs of infection under treatment. In three patients, sc PSAT had to be discontinued due to side effects; in only one of these was the sc route implicated (skin necrosis following direct sc injection and not gravity infusion). Median treatment duration was 433 days. In six patients, sc PSAT was successful with favourable outcome at the time of writing. Interestingly, three patients with MDR bacterial carriage at baseline lost this under PSAT during follow-up. As salvage therapy, sc PSAT delivered by gravity infusion is a safe and interesting alternative when an optimal surgical strategy is not feasible and no oral treatment is available.

1014. Microbiology and Outcome of Bloodstream Infections in Children With Intestinal Failure

BackgroundChildren with intestinal failure (IF) represent 20% of bloodstream infection (BSI) pediatric hospitalizations. We studied the microbiology and associated outcomes of this population.MethodsRetrospective cohort study of children ≤18 years with IF dependent on parenteral nutrition (PN), with ≥1 BSI from January 2007 to December 2016. Organisms causing BSI were divided into skin or GI bacteria and fungi based on human habitat and kingdom. The impact of ethanol lock therapy (ELT) and clinical diagnosis of small intestine bacterial overgrowth (SIBO) on the type of these organisms was evaluated. Antimicrobial utilization and outcome measures for BSI were collected.ResultsThere were 254 BSIs in 54 children resulting from GI bacteria (58%), skin bacteria (39%), and fungi (16%) with 11% containing >1 group. The proportion of skin bacteria was significantly higher on ELT (27% off vs. 45% on ELT; P = 0.003), while the proportion of GI bacteria was lower (67% off vs. 52% on ELT; P = 0.018). Significantly more fungal BSIs were seen in older children: mean age 4.2 years (95% CI: 2.9–5.5) vs. 2.7 years (95% CI: 2.3–3) with other organisms; P = 0.014. Fungal BSIs were more common with SIBO (18% vs. 5% with and without SIBO; P = 0.013). Twenty-eight organisms were resistant to ceftazidime, and five to cefepime. Hospitalization days totaled 2,432 (median 8 days), with 21 pediatric critical care admissions totaling 156 days. There were six deaths, none related to BSI, 18/54 children were weaned off PN, and four had liver and intestinal transplants. Median course of antimicrobial therapy was 14 days.ConclusionThe majority BSIs in children resulted from GI bacteria, suggesting intestinal translocation; these infections were not less common in older children despite increased intestinal mass, signifying continued translocation. BSI with GI organisms was not more common in children with SIBO despite increased intestinal bacterial load, possibly due to antibiotic suppressive therapy, which instead lead to more fungal BSIs. Prevention of BSI by ELT was less effective for skin bacteria which may require different regimens or strategies. BSI causes frequent and prolonged hospitalizations including need for intensive care, but deaths are rare.Disclosures All authors: No reported disclosures.

322. Joint Spacer Retention, Antimicrobial Suppression, and Risk of Re-infection

BackgroundTwo-stage exchange is the standard treatment of periprosthetic joint infection in the United States. Occasionally, for selected patients, temporary antibiotic-loaded spacers are retained “permanently” instead of proceeding with prosthesis re-implantation. It is unclear whether the “retained” spacer represents a nidus for re-infection, and would require secondary antibiotic suppression to prevent recurrence of infection. We aim to determine the risk of re-infection among patients with retained knee and hip spacers, and assess the role of antibiotic suppression.MethodsWe identified 51 patients with retained static or articulating knee (n = 34) and hip (n = 17) spacers between 1996 and 2014 using the Mayo Clinic Hospital Orthopedic database. Medical records were reviewed to collect clinical data, including antibiotic use and offending organisms. We compared the cumulative incidence of reinfection between those with or without suppression using a competing risk model, with death and revision for mechanical failure as competing risks.ResultsThe median age was 77 years (range, 48–94). Gender distribution was equal. The median Charlton Comorbidity Index (CCI) was 3 (1–11), while median BMI was 30.1 (17.8–59.5). Eleven of 51 patients received antibiotic suppression after spacer retention. A history of prior antibiotic suppressive therapy was the only variable associated with being placed back on antibiotic suppression after spacer retention [OR 18 (95% CI 3.2–100)]. During the median follow-up period of 31.3 months, there were five re-infections. The cumulative incidence of re-infection was not significantly different between suppressed and unsuppressed groups (P = 0.89). The re-infecting pathogens were different from the index offending organisms. Only the presence of preoperative draining sinus was significantly associated with re-infection [OR 10 (95% CI 1–99.6)].ConclusionIn selected patients where a second-stage prosthesis re-implantation is not an option, and retention of “temporary” antibiotic loaded spacer is surgically preferred, the risk of re-infection was not prevented by prolonged antibiotic suppression. The presence of a draining sinus was significantly associated with re-infection, often with new pathogens.Disclosures All authors: No reported disclosures.

290. Safety and Effectiveness of Oral Sodium Fusidate (Fusidic Acid) as Chronic Antibiotic Suppressive Therapy in Patients With Staphylococcal Bone or Joint Infections

BackgroundFusidic acid (FA) is an anti-staphylococcal agent used to treat chronic bone and joint infections (BJI) due to the availability of an oral formulation and its MRSA activity. Though used widely throughout the world for decades, FA is not approved in the USA.MethodsTo evaluate the safety and effectiveness of FA as chronic suppressive therapy in patients with staphylococcal BJI, we enrolled 30 patients in a prospective, single-arm, multi-center study in the USA. Eligible patients had refractory infections that could not be managed surgically and/or had not responded to previous antibiotic treatment. In Part A of the study, all patients received 6 months of oral FA treatment. In the first 1–2 weeks, patients could receive a companion antibiotic. Clinical success was based on lack of need for surgery or additional antibiotics. After all patients completed Part A of the study, an interim analysis was performed. In Part B of the study (ongoing), patients who completed Part A and require continued suppressive therapy may continue to receive FA for a total of 24 months.ResultsMost patients (83%) had orthopedic hardware infections. Therapy was considered successful at the 6-month visit in 18 patients (60%). Microbiological persistence was observed in eight patients, with three cases of decreasing FA susceptibility (including one case of resistance). Among 29 patients who experienced a treatment-emergent adverse event (TEAE), the most frequently reported events were: urinary tract infection (n = 9), peripheral edema/swelling (n = 8), nausea/dyspepsia (n = 7). Seven patients experienced TEAEs related to study drug; mild gastrointestinal disorders were most common. Two treatment-related events (unrelated to therapeutic failure) led to discontinuation of study drugConclusionPatients with refractory BJI have few treatment options. In our study, 60% of infections were effectively suppressed for 6 months with FA treatment. The frequency of TEAEs was high, though not unexpected in this population with many chronic diseases. FA was well-tolerated with few patients experiencing treatment-related AEs leading to study drug discontinuation. FA administered chronically as monotherapy may lead to decreasing susceptibility and treatment failure in some patients; thus, combination therapy is warranted for this indication.Disclosures A. Sheets, Melinta Therapeutics: Employee, Salary. D. Graham, Cempra: Grant Investigator, Research grant. R. Darouiche, Cempra: Grant Investigator, Grant recipient. A. Strayer, Melinta Therapeutics, Inc.: Employee and Shareholder, Salary.

1087. Aortic Graft Infections Caused by Propionibacterium acnes at the Minneapolis Veterans Affairs Health Care System (MVAHCS) 2007–2017

Background Propionibacterium acnes is a Gram-positive microaerophilic bacterium and part of the human skin flora. The ability of P. acnes to cause infections has been recognized, particularly in the presence of hardware. We aimed to define the frequency of P. acnes infections, with a focus on aortic graft infection.MethodsWe used microbiology laboratory records at the Minneapolis Veterans Affairs Health Care System to identify all P. acnes cultures from January 2007 to January 2017. We retrospectively reviewed all adult (≥18 years) patient’s medical records to identify associated infectious syndromes. Case definitions by the management of Aortic Graft Infection Collaboration were used to classify aortic graft infection cases.ResultsWe identified 328 positive P. acnes cultures during the study period. P. acnes was classified as a pathogen in 48 (15%), a pathogen of undetermined significance in 70 (21%), and a contaminant in 210 (64%) cases. We identified three cases aortic graft infection which accounted for (2.5%) of infections caused by P. acnes. Median age (range) at presentation was 74 years (67–83). Symptoms included pain (n = 3), fever (n = 2), and altered mental status (n = 1). None were hypotensive. All patients had at least one revision for endoleak prior to presentation. Median time from symptom onset to diagnosis was 120 days (78–140). Microbiological diagnosis was obtained by blood cultures, percutaneous peri-graft tissue aspiration, and operative culture in each patient, respectively. Infection was complicated by metastatic abscess in one patient. All cultures grew on Day 7. All patients were treated with IV ceftriaxone, and two were transitioned to life-long oral suppressive antibiotic therapy. Two patients had complete removal of infected material. No relapse was documented and survival was 100% at 1 year follow-up.ConclusionAortic graft infection is an uncommon subset of infections caused P. acnes. Clinical course is indolent and diagnosis is delayed due to nonspecific clinical presentation. In contrast to endovascular graft infection caused by other organisms, mortality is low when treated with appropriate antibiotic therapy and removal of infected material. The current laboratory practice of holding blood cultures for 5 days may need to be altered when P. acnes is a potential cause of infection.Disclosures All authors: No reported disclosures.

Late Acute Periprosthetic Joint Infections; When Should the Implant Be Removed?

Background: Late acute (LA) periprosthetic joint infections (PJI) treated with surgical debridement and implant retention (DAIR) have a high failure rate. Therefore, we evaluated treatment outcome in LA PJIs treated with DAIR versus implant removal. Methods: In a large multicenter study, LA PJIs of the hip and knee were retrospectively evaluated. Failure was defined as: PJI related death, prosthesis removal or the need for suppressive antibiotic therapy. LA PJI was defined as acute symptoms <3 weeks and more than 3 months after the index surgery. Findings: A total of 445 patients were included, comprising 340 cases treated with DAIR and 105 cases treated with implant removal (19% one-stage revision (n=20), 74.3% two-stage revision (n=78) and 6.7% definitive implant removal (n=7). Overall treatment failure was 45.0% in the DAIR group versus 24.8% in the implant removal group (p < 0.001). This difference remained after 1:1 propensity-score matching. DAIR was an independent predictor for failure in the multivariate analysis (OR 2.7, p 0.006). A high preoperative risk score for DAIR failure defined by a CRIME80 score ≥3, demonstrated a failure rate of 68.7% (57/83) in the DAIR group and a 16.7% failure rate (4/24) in the implant removal group (p < 0.0001). No significant difference in failure was observed with a CRIME80 score <3 (35.7% versus 23.9%, respectively (p 0.07). Interpretation: Implant removal is associated with significantly better outcomes compared to DAIR in LA PJI with a high CRIME80 score and this should be taken into consideration when choosing the surgical strategy. Funding: No funding was obtained for this study. Declaration of Interest: The authors state no conflict of interest. Ethical Approval: Informed consent was retrieved when required by the ethics committee of the participating center.

Use of gentamicin-impregnated beads or sponges in the treatment of early acute periprosthetic joint infection: a propensity score analysis.

Early acute periprosthetic joint infections (PJIs) treated with debridement, antibiotics and implant retention (DAIR) have failure rates ranging from 10% to 60%. We determined the efficacy of applying local gentamicin-impregnated beads and/or sponges during debridement in early PJI. Patients with early acute PJI, defined as less than 21 days of symptoms and treated with DAIR within 90 days after index surgery, were retrospectively evaluated. Early failure was defined as PJI-related death, the need for implant removal or a second DAIR or antibiotic suppressive therapy owing to persistent signs of infection, all within 60 days after initial debridement. Overall failure was defined as implant removal at any timepoint during follow-up. A 1:1 propensity score matching was performed to correct for confounding factors. A total of 386 patients were included. Local gentamicin was applied in 293 patients (75.9%) and was withheld in 93 patients (24.1%). Multivariate analysis demonstrated that the use of local gentamicin was independently associated with early failure (OR = 1.97, 95% CI = 1.12-3.48). After propensity matching, early failure was 40.3% in the gentamicin group versus 26.0% in the control group (P = 0.06) and overall failure was 5.2% in the gentamicin group versus 2.6% in the control group (P = 0.40). These numbers remained when solely analysing the application of gentamicin-impregnated sponges. Even after propensity score matching, failure rates remained higher if local gentamicin-impregnated beads and/or sponges were administered in early acute PJI. Based on these results, their use should be discouraged.

Clinical outcome and risk factors for failure in late acute prosthetic joint infections treated with debridement and implant retention

Debridement, antibiotics and implant retention (DAIR) is the recommended treatment for all acute prosthetic joint infections (PJI), but its efficacy in patients with late acute (LA) PJI is not well described. Patients diagnosed with LA PJI between 2005 and 2015 were retrospectively evaluated. LA PJI was defined as the development of acute symptoms (≤ 3 weeks) occurring ≥ 3 months after arthroplasty. Failure was defined as: (i) the need for implant removal, (ii) infection related death, (iii) the need for suppressive antibiotic therapy and/or (iv) relapse or reinfection during follow-up. 340 patients from 27 centers were included. The overall failure rate was 45.0% (153/340). Failure was dominated by Staphylococcus aureus PJI (54.7%, 76/139). Significant independent preoperative risk factors for failure according to the multivariate analysis were: fracture as indication for the prosthesis (odds ratio (OR) 5.4), rheumatoid arthritis (OR 5.1), age above 80 years (OR 2.6), male gender (OR 2.0) and C-reactive protein > 150 mg/L (OR 2.0). Exchanging the mobile components during DAIR was the strongest predictor for treatment success (OR 0.35). LA PJIs have a high failure rate. Treatment strategies should be individualized according to patients' age, comorbidity, clinical presentation and microorganism causing the infection.

Endovascular Aneurysm Repair Complicated with Type Ia Endoleak and Presumable Infection Treated with a Fenestrated Endograft.

An 81-year-old patient presented to the emergency room 5 years after infrarenal endovascular aneurysm repair, with a Type Ia endoleak and a presumable infection of the graft material with Listeria monocytogenes . He was treated with a custom-made fenestrated endograft to seal the endoleak and lifelong antibiotic therapy to suppress the infection. Full explantation of graft material is not always preferable, and endovascular treatment combined with antibiotic suppressive therapy is in some cases an appropriate alternative.

Staphylococcus aureus bloodstream infection in patients with ventricular assist devices–Management and outcome in a prospective bicenter cohort

Ventricular assist devices (VAD) are increasingly implanted in patients with terminal heart failure. Here we describe the clinical course, management and outcome of VAD patients with S. aureus bloodstream infection (SAB). We conducted a post hoc analysis of data from 1073 patients who had been prospectively enrolled in two consecutive SAB bicenter cohort studies. Patients with VAD in situ at the onset of SAB were identified. Follow-up of patients was at least 90 days. Twelve VAD patients with SAB were identified. Compared to the overall cohort, patients with VAD presented more often with fever (92% vs. 65%) and septic shock (33% vs. 23%) and showed higher C-reactive protein levels (mean 244 vs. 132 g/ml). The median time to onset of SAB after device implantation was 161 days (range 24-790 days). 30-day mortality was comparable to the whole cohort (17% vs. 19%). Infection-related surgical interventions were performed in six patients. Hematogenous dissemination to distant foci was not found in any patient. One out of nine surviving patients required continuous suppressive antibiotic therapy. Mortality rates for VAD patients with SAB were comparable to SAB without VAD. No hematogenous disssemination or persistent infections were recorded, which might be associated with the prompt and aggressive antibiotic and surgical management in VAD patients. SAB per se does not preclude successful transplantation.

Mycotic aneurysm caused by Edwardsiella tarda successfully treated with stenting and suppressive antibiotic therapy: a case report and systematic review

BackgroundMycotic aneurysm is an uncommon disease which could be fatal without appropriate treatment. Although standard therapy for mycotic aneurysms consists of resection of the infected aorta and in situ graft replacement, some treat with endovascular stent-grafting because patients may not tolerate graft replacement due to underlying diseases. There are 6 more reported cases of mycotic aneurysm caused by Edwardsiella tarda. With the exception of our case, all underwent resection and debridement of the infected aorta or vascular prosthesis. Herein we report the first case ever of mycotic aneurysm caused by E. tarda, successfully treated with stenting and suppressive antibiotic therapy without resection of the infected aorta.Case presentationA 65-year-old Japanese woman with cirrhosis and hepatocellular carcinoma complained of fatigue. Her work up revealed a ruptured aneurysm of the descending aorta. She went through endovascular stent-graft placement. Edwardsiella tarda grew from blood cultures, which led to the diagnosis of mycotic aneurysm. Edwardsiella tarda is a Gram negative bacillus which rarely causes infections in humans. In the case of bacteremia, its mortality is reported to be very high and all reported cases with mycotic aneurysm caused by E. tarda ended up with resection of the infected aorta.ConclusionOur case shows that in the case of mycotic aneurysm caused by E. tarda, endovascular stent-graft placement could be an alternative to in situ graft replacement.

Electronically Available Comorbid Conditions for Risk Prediction of Healthcare-Associated Clostridium difficile Infection.

OBJECTIVE To analyze whether electronically available comorbid conditions are risk factors for Centers for Disease Control and Prevention (CDC)-defined, hospital-onset Clostridium difficile infection (CDI) after controlling for antibiotic and gastric acid suppression therapy use. PATIENTS Patients aged ≥18 years admitted to the University of Maryland Medical Center between November 7, 2015, and May 31, 2017. METHODS Comorbid conditions were assessed using the Elixhauser comorbidity index. The Elixhauser comorbidity index and the comorbid condition components were calculated using the International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM) codes extracted from electronic medical records. Bivariate associations between CDI and potential covariates for multivariable regression, including antibiotic use, gastric acid suppression therapy use, as well as comorbid conditions, were estimated using log binomial multivariable regression. RESULTS After controlling for antibiotic use, age, proton-pump inhibitor use, and histamine-blocker use, the Elixhauser comorbidity index was a significant risk factor for predicting CDI. There was an increased risk of 1.26 (95% CI, 1.19-1.32) of having CDI for each additional Elixhauser point added to the total Elixhauser score. CONCLUSIONS An increase in Elixhauser score is associated with CDI. Our study and other studies have shown that comorbid conditions are important risk factors for CDI. Electronically available comorbid conditions and scores like the Elixhauser index should be considered for risk-adjustment of CDC CDI rates. Infect Control Hosp Epidemiol 2018;39:297-301.

Spotlight - Management of pyelovesical bypass device stones.

Pyelovesical bypass devices or artificial ureters have been described as a last resort in patients with long ureteral strictures that fail traditional endoscopic and open repair. Herein, we describe a 52-year-old female who had a Detour (Coloplast, Humlebaek, Denmark) pyelovesical bypass device inserted after an iatrogenic ischemic injury to the distal two-thirds of the left ureter during pelvic surgery for recurrent endometrial stromal sarcoma. Six months after placement of the device, she presented with gross hematuria and recurrent urinary tract infections (UTIs) and was found to have encrustation of the distal silicone tip of the Detour device within the bladder. This was managed with resection of the distal silicone tip and flexible ureteroscopy with holmium laser lithotripsy. Despite suppressive antibiotic therapy and medical therapy for hypercalciuria, she presented four years later with intraluminal encrustations in the proximal end of the device. This was successfully managed with flexible ureteroscopy with holmium laser lithotripsy. Therefore, this case illustrates the feasibility of flexible ureteroscopy and holmium laser lithotripsy of Detour device encrustations as long as the device is not kinked and it allows the passage of the flexible ureteroscope up to the calcifications. In addition, patients contemplating insertion of such devices should be counselled regarding the risk of recurrent infections and encrustations.

The fate of immunocompromised patients in the treatment of chronic periprosthetic joint infection: a single-centre experience

Immunocompromised patients with periprosthetic joint infection (PJI) are rare and currently there are no reliable guidelines according to which these infections can be successfully managed. The purpose of this study was to report the clinical course of different strategies for treatment of PJI in frail patients. A retrospective analysis between 2004 and 2015 included 29 immunocompromised patients (13 hips and 16 knees) with chronic PJI who underwent one-stage revision or debridement, antibiotics and implant retention (DAIR). Patients were stratified according to the Musculoskeletal Infection Society (MSIS) staging system and the clinical course included recurrence of infection and functional outcomes which were extracted from patients' charts. The average follow-up was 68months (range, 26-149months). Sixteen of the 29 patients had recurrent infections. At last follow-up, 13 patients were on chronic suppressive antibiotic therapy, three patients died but not one death was considered to be related to the infection. A recurrent infection was observed in 13 of the 24 medically compromised hosts (MSIS type B). Sixteen of the 24 patients underwent one-stage revision; another eight of them underwent DAIR. The infection recurred in three of the five patients (60%) with the worst host grades (MSIS type C). One-stage revision was performed in one of the five patients and the remaining four patients received DAIR. Our results show that we should compromise our expectation and intemperate treatment for such a population. The goals of PJI treatment in these patients should take into account their preferences and may pay more attention to the concept of disease control rather than cure, especially for patients with severe comorbidities (MSIS C). Therapeutic Level IV.