Antibiotic Suppression Research Articles

Risk of Periprosthetic Joint Infection in Patients With Multiple Arthroplasties

BackgroundRisk of subsequent periprosthetic joint infection (PJI) in a second prosthetic joint following initial PJI has been shown to be 19%-20%. We sought to identify (1) the risk of developing a second PJI for our patients with multiple prosthetic joints and (2) the effect of bacteremia on development of a subsequent PJI. MethodsWe retrospectively reviewed all patients treated surgically for PJI by a single surgeon from 2003 to 2014. Time between initial and subsequent infection, bacteremia, and risk factors for PJI were identified. ResultsOf 167 patients treated for PJI, 76 had multiple prosthetic joints. Thirteen percent (10/76) developed a PJI in a second location. Excluding simultaneous infections, the rate was 8.3% (6/72), despite having a 57% incidence of immunosuppression, diabetes, renal failure, smoking, or steroid use. Average follow-up for patients with 1 PJI was 4.6 years (range 0.03-13.6). Seventy percent (7/10) of patients with multiple infections were bacteremic at the time of initial infection compared to 18.1% (12/66) of patients with a single infection (P = .0004). Excluding the 4 simultaneous infections (all bacteremic), the risk of developing an infection in a second joint was 20% if bacteremic and 5.2% if not bacteremic. ConclusionOur study identified the risk of developing a subsequent PJI to be one half of previous studies. Bacteremia at the time of PJI is an important factor for developing subsequent PJI. Multiple prosthetic joints may be less hazardous than previously thought for patients with PJI suggesting that suppressive antibiotics may only be necessary in cases with bacteremia.

Continuous betadine-bacitracin irrigation for vascular graft infections: A case series

The aim of the study was to conduct a retrospective chart review of patients who underwent betadine/bacitracin continuous irrigation (BBCI) for vascular graft infections (VGIs) to review its use as a treatment option. A retrospective chart review from 2013 to 2017 was conducted of patients with VGIs that were treated with BBCI postremoval of the infected graft. The BBCI is a continuous infusion of 0.25% betadine in normal saline at 0.3mL/kg/h for 48hours then followed by bacitracin infusion with a concentration of 50,000 units bacitracin/per liter normal saline at 0.3mL/kg/h for 72hours. Descriptive statistics were used to describe the sample. The nine adult patients who received postoperative BBCI had an age range of 30-81years, with average age of 58.8 years. Five of the subjects were females with four males. A total of nine patients with groin infections were identified, with two aortobifemoral bypasses, two axillofemoral bypasses, three femoral-femoral bypasses, one femoral artery pseudoaneurysm repair with Dacron patch, and one common femoral endarterectomy with Dacron patch. VGIs were identified from 10days up to 72months from the original vascular procedure. Six patients had negative wound cultures, while two had wound cultures positive for methicillin-resistant Staphylococcus aureus and one patient had positive culture for Escherichia coli. The length of time of BBCI ranged from 48 to 84hours with average of 57.6hours (standard deviation [SD]=12.7hours). The length of time of the bacitracin irrigation ranged from 30 to 72hours with average of 48.4hours (SD=14.9hours). All patients healed their groin wounds except for an 81-year-old patient with aortobifemoral bypass graft who developed ischemic bowel and expired. Patients received at least 6weeks of intravenous antibiotics followed by oral antibiotic suppression therapy for life. VGIs are a devastating complication associated with a high morbidity. BBCI provides an option for antiseptic irrigation of the vascular graft site postgraft removal to promote wound closure.

Current treatments in periprosthetic shoulder infections

Management of shoulder arthroplasty infections can be challenging. The most common organisms that are isolated from shoulder arthoplasty infections are Propionibacter acnes and Staphylococcus species. Treatment algorithms tend to be unclear, especially in the setting of unexpected positive cultures and in Propionibacter acnes infections, but they include antibiotic suppression, tissue debridement with retention of the prosthesis, one or two-stage prosthesis exchange, and resection arthroplasty. Prevention of infection is paramount, with the use of antibiotics and proper preoperative skin preparation. Our goal was to review the current literature in diagnosing and managing shoulder arthroplasty infections.

Vancomycin Povidone-Iodine Protocol Improves Survivorship of Periprosthetic Joint Infection Treated With Irrigation and Debridement

BackgroundIrrigation and debridement with modular component and liner exchange (IDLE) is a low morbidity procedure for treatment of periprosthetic joint infection (PJI) with reported failure rates exceeding 50%. Dilute povidone-iodine lavage has been shown to be safe and effective in decreasing acute PJI in primary total joint arthroplasty. Vancomycin powder has also shown to be effective in preventing infection in spine surgery. We hypothesize that a vancomycin povidone-iodine protocol (VIP) used in conjunction with IDLE can increase infection-free survivorship after acute PJI. MethodsThis is a single institution retrospective review of all PJIs treated with IDLE and VIP since March 2014. A consecutive matched control group of patients treated with IDLE for PJI for 2 years prior to March 2014 was also included for analysis. Primary outcome was failure, defined as return to operating room for an infection-related problem. Secondary outcome was chronic suppression with antibiotics at final follow-up. Minimum follow-up was 1 year. ResultsA total of 36 patients in the VIP group and 38 patients in control group were identified. In the VIP group, 16.7% (6/36) failed at final follow-up compared to 37% failure rate (14/38) in the control group (P < .05). Three patients in the VIP group were on chronic antibiotic suppression at final follow-up. There were no medical complications secondary to the VIP. ConclusionsThe VIP group demonstrated a significant reduction in reinfection and failure rate following IDLE. The authors believe that a VIP is an effective adjunct for treating PJI with irrigation and debridement.

Suppressive antibiotic therapy with oral tetracyclines for prosthetic joint infections: a retrospective study of 78 patients.

This study aimed at describing the use of oral cyclines (i.e., doxycycline and minocycline) as suppressive antibiotic therapy (SAT) in patients with periprosthetic joint infections (PJIs). Medical charts of all patients with surgical revisions for PJIs who were given cycline-based SAT because of a high failure of various origins were reviewed. Data regarding tolerability and effectiveness of cycline-based SAT were analysed. Seventy-eight patients of mean age 64±17years received cycline-base SAT in the period from January 2006 to January 2014. PJIs involved the knee in 37 patients (47%), the hip in 35 (45%), the elbow in 4 (5%), and the shoulder in 2 (3%) and were qualified as early in 31 patients (39.7%). Staphylococcus spp. were the most common pathogens accounting for 72.1% of the total number of bacterial strains identified. All included patients had surgery which consisted in debridement and implant retention in 59 of them (75.6%). Doxycycline and minocycline were prescribed as SAT in 72 (92%) and 6 (8%) patients, respectively. Adverse events were reported in 14 patients (18%), leading to SAT discontinuation in 6 of them (8%). After a mean follow-up of 1020±597days, a total of 22 (28.2%) patients had failed including 3 cases (3.8%) with documented acquisition of tetracycline resistance in initial pathogen(s). Our results suggest that oral cyclines used as SAT in patients treated for PJI have an acceptable tolerability and effectiveness and appear to be a reasonable option in this setting.

Osteomyelitis of the Pelvic Bones: A Multidisciplinary Approach to Treatment.

Background and Purpose: A case series review of chronic pelvic osteomyelitis treated with combined medical and surgical treatment by a multidisciplinary team.Methods: All patients treated with surgical excision of pelvic osteomyelitis at our tertiary referral centre between 2002 and 2014 were included. All received combined care from a clinical microbiologist, an orthopaedic surgeon and a plastic surgeon. The rate of recurrent infection, wound healing problems and post-operative mortality was determined in all. Treatment failure was defined as reoperation involving further bone debridement, a requirement for the use of long-term suppressive antibiotics or sinus recurrence.Results: Sixty-one adults (mean age 50.2 years, range 16.8-80.6) underwent surgery. According to the Cierny-Mader classification of osteomyelitis there were 19 type II, 35 type III and 7 type IV cases. The ischium was the most common site of infection. Osteomyelitis was usually the result of contiguous focus infection associated with decubitus ulcers, predominantly in patients with spinal or cerebral disorders. Most patients with positive microbiology had polymicrobial infection (52.5%). Thirty patients required soft tissue reconstruction with muscle or myocutaneous flaps.Twelve deaths occurred a mean of 2.8 years following surgery (range 7 days-7.4 years). Excluding these deaths the mean follow-up was 4.6 years (range 1.5-12.2 years). Recurrent infection occurred in seven (11.5%) a mean of 1.5 years post-operatively (92 days - 5.3 years). After further treatment 58 cases (95.1%) were infection free at final follow-up.Interpretation: Patients in this series have many comorbidities and risk factors for poor surgical outcome. Nevertheless, the multidisciplinary approach allows successful treatment in the majority of cases.

A Large Spontaneous Esophageal Perforation Treated With Endoscopic Stent Placement

Esophageal perforations are extremely rare, with an incidence of 3.1 per 1,000,000 annually. About 15% are spontaneous, usually referred to as Boerhaave's syndrome, which occurs due to increased intraluminal pressure with inability of upper esophageal sphincter to relax during retching. However, a spontaneous perforation without such an inciting event is even more infrequent. An 88 year-old male with no prior medical history presented with chest pain, dyspnea and worsening acid reflux. Preliminary workup was concerning for a cardiac event, for which he underwent a cardiac catherization with stent placement. However, he continued to have chest pain, thus a CTA chest/abdomen/pelvis was performed, and revealed a likely hiatal hernia with significant reflux, however otherwise normal. Three days later a CXR showed a left pleural effusion, and eventually a CT chest revealed oral contrast in the left thorax with significant pneumomediastinum, suspicious for an esophageal perforation. He was transferred to the surgical ICU, kept NPO, started on empiric antibiotic, antifungal, and acid suppression therapy. The cardiothoracic surgical team placed two chest tubes. He then had an esophagram, showing a large esophageal defect with free extravasation of contrast into the mediastinum. Given that he was deemed a poor surgical candidate, he was taken to the OR for endoscopic stent placement. EGD revealed a large, 5cm perforation in the distal esophagus. No esophagitis or tumor was seen. Successful placement of two fully covered metal stents achieved adequate closure of the defect. Taking into account the lack of typical symptoms, typical inciting events, and overall patient tolerance of such a large perforation, this is a highly unusual case and suggests a possibly chronic underlying defect. Diagnosis of spontaneous esophageal perforation is often delayed as the classic triad of vomiting, chest pain and subcutaneous or mediastinal air, is only described in 50% of cases. Esophageal stents are an alternative to surgical treatment of perforations. Although esophageal stent placement successfully sealed the majority of our patients' perforation, a defect of this size will likely require surgical repair. This case emphasizes the importance of prompt recognition of a suspected esophageal perforation, the importance and diagnostic accuracy of CT scan with PO contrast and the potential role of fully covered metal stents as a therapeutic alternative to emergent surgery. Watch the video: https://goo.gl/fhkDGTFigure: CT chest/abdomen with IV and PO contrast demonstrating pneumomediastinum and oral contrast in the mediastinum.Figure: Fluoroscopic images from gastrograffin esophagram revealing large area of extravasation into the left mediastinum.

Subcutaneous Suppressive Antibiotic Therapy for Bone and Joints Infections: Safety and Outcome in a Cohort of 10 Patients

Background Optimal surgical therapy could be sometimes non-feasible, especially in the elderly population. Therefore, a medical therapy with oral prolonged suppressive antibiotic therapy (PSAT) seems to be an option to prevent recurrence and prosthesis loosening. Subcutaneous (SC) administration of injectable intravenous antibiotics as PSAT could be a convenient way when oral treatment is not available to facilitate ambulatory care, even if this practice is considered as an “off-label” practice.Methods All patients receiving SC PSAT since 2010 were prospectively enrolled in a cohort study evaluating treatment modalities, efficacy, and safety. Success was defined by the absence of clinical signs of infection at the time of last follow-up.ResultsWe included 10 patients (median age of 79 years): seven had PJI and three chronic osteomyelitis. Six had plurimicrobial infections and four had infections due to multidrug-resistant Gram-negative pathogens. Suboptimal surgery was performed in seven patients, and three received only antibiotics. All patients received an induction-phase therapy with conventional antibiotic treatment before SC PSAT. For nine patients, SC injections were delivered by a 50 mlml 30 minute gravity infusion of the antibiotic, using butterfly disposable needle. One patient received direct flash SC administration. The most frequent drug used was ertapenem (n = 7; 1–2 g/day), followed by ceftriaxone (n = 2; 1 g/day), and ceftazidime (n = 1; 2 g/day). The dose was adjusted depending on the results of trough residual blood concentration. Median duration of treatment was 6 months (from 1 to 58 months), corresponding to a total of about 5,000 SC injections. SC PSAT had to be discontinued for side effects in only two patients, including skin necrosis in the patient receiving direct SC infusion (lost to follow-up after treatment discontinuation) and epilepsy under ertapenem therapy (with relapse of the BJI after the treatment discontinuation). One other patient experienced a relapse despite the SC PSAT. Finally, SC PSAT was still ongoing in seven patients with a favorable outcome at the last follow-up.Conclusion SC PSAT appears to be a safe and effective alternative therapy when optimal surgical strategy is not feasible and when oral treatment is not available.Disclosures T. Ferry, HERAEUS: Consultant, Speaker honorarium. S. Lustig, Heraeus: Consultant, Consulting fee

Treatment of Aortic Graft Infection in the Endovascular Era.

This review provides an overview of the current literature surrounding the medical and surgical treatment of aortic graft infection with particular focus on the role of endovascular aortic grafts in the changing demographics and management of these infections. Definitive therapy for aortic graft infection continues to include parenteral antibiotics and surgical explantation and revascularization procedures, which are historically vast operations and sources of significant operative stress. Surgical management has evolved to include more options for infection resistant in situ conduits, attempts at partial explantations, and use of endovascular therapy to temporize the urgent sequelae of these infections, such as aortoenteric fistula. Aortic graft infection continues to be a significant and morbid complication of graft placement even with the advent of endovascular therapy, and its treatment will only increase in difficulty as a more frail population has gained access to complex aortic repair. In the future, more flexible revascularization and partial explantation options are keys, along with long-term suppressive antibiotics where appropriate.

Intravenous drug abuse is a risk factor in the failure of two-stage treatment for infected total hip arthroplasty

Reinfection after two-stage revision hip arthroplasty (RHA) is still a complex issue. Only few studies revealed the factors affecting the success rate in the treatment of periprosthetic hip infection (PHI), especially risk factors. A retrospective study was conducted using records of 30 patients underwent two-stage RHA for infected total hip arthroplasty (THA). Treatment was defined as successful if a patient did not need any reoperation or invasive procedure such as image-guided drainage during the two years after reimplantation. Treatment was defined as failure if any surgery or invasive procedure or long-term antibiotic suppression was considered necessary to control infection. Four patients had infection recurrence defined as failed and three of them had intravenous drug abuse. Twenty-six patients had no infection recurrence at the end of follow-up and one of them had intravenous drug abuse but quitting after surgery. We suggest that once adequate cleaning up achieved, risk of reinfection may be little even in immunocompromised patients with RHA because of relative less old age than those with revisional total knee arthroplasty. Patients of the reinfection group were younger and non-obese with adequate nutritional status. We may consider intravenous drug abuse could take a great toll on health and lead to reinfection. Finally, we suggest performing the gold-standard two-stage reimplantation technique to manage cases with infection, educating drug abusers regarding the risk of surgical failure, and implementing a quitting program at least 1 year before the index surgery.

Caterpillars lack a resident gut microbiome

Many animals are inhabited by microbial symbionts that influence their hosts' development, physiology, ecological interactions, and evolutionary diversification. However, firm evidence for the existence and functional importance of resident microbiomes in larval Lepidoptera (caterpillars) is lacking, despite the fact that these insects are enormously diverse, major agricultural pests, and dominant herbivores in many ecosystems. Using 16S rRNA gene sequencing and quantitative PCR, we characterized the gut microbiomes of wild leaf-feeding caterpillars in the United States and Costa Rica, representing 124 species from 15 families. Compared with other insects and vertebrates assayed using the same methods, the microbes that we detected in caterpillar guts were unusually low-density and variable among individuals. Furthermore, the abundance and composition of leaf-associated microbes were reflected in the feces of caterpillars consuming the same plants. Thus, microbes ingested with food are present (although possibly dead or dormant) in the caterpillar gut, but host-specific, resident symbionts are largely absent. To test whether transient microbes might still contribute to feeding and development, we conducted an experiment on field-collected caterpillars of the model species Manduca sexta Antibiotic suppression of gut bacterial activity did not significantly affect caterpillar weight gain, development, or survival. The high pH, simple gut structure, and fast transit times that typify caterpillar digestive physiology may prevent microbial colonization. Moreover, host-encoded digestive and detoxification mechanisms likely render microbes unnecessary for caterpillar herbivory. Caterpillars illustrate the potential ecological and evolutionary benefits of independence from symbionts, a lifestyle that may be widespread among animals.

Suppressive antibiotic therapy with oral doxycycline for Staphylococcus aureus prosthetic joint infection: a retrospective study of 39 patients

The aim of this study was to describe the use of oral doxycycline as suppressive antibiotic therapy (SAT) in patients with Staphylococcus aureus periprosthetic (hip or knee) joint infections. The medical charts of all patients with surgical revisions for S. aureus hip or knee prosthetic joint infections (PJIs) who were given doxycycline-based SAT because of a high risk of failure of various origins were reviewed. Data regarding tolerability and effectiveness of doxycycline-based SAT were analysed. A total of 39 patients (mean age 66.1 ± 16.3 years) received doxycycline-base SAT in the period from January 2006 to January 2014. PJIs involved the hip in 23 patients (59.0%) and the knee in 16 (41.0%), and were qualified as early in 15 patients (38.5%). Methicillin-resistant S. aureus (MRSA) accounted for 22% of the total number of bacterial strains identified. All patients included in the study had surgery, which consisted of debridement and implant retention in 32 (82.1%). Adverse events likely attributable to SAT were reported in six patients (15.4%), leading to discontinuation of SAT in three (7.7%). A total of 29 patients (74.4%) remained event-free and 10 (25.6%) failed, including 8 (20.5%) relapses and 2 (5.1%) superinfections. Overall, 8 of the 10 failure cases were related to a doxycycline-susceptible pathogen. These results suggest that oral doxycycline used as SAT in patients treated for S. aureus hip or knee PJIs has an acceptable tolerability and effectiveness and appears to be a reasonable option in this setting.

Reconstruction of the distal tibia following resection of aggressive bone tumours using a custom-made megaprosthesis

ObjectiveLargest, single-centre study of clinical and functional outcomes of patients who underwent endoprosthetic replacement (EPR) for aggressive distal tibial bone tumours. MethodRetrospective observational study of eight patients was undertaken. ResultsMedian follow-up was 77 months (range 13–276). Cumulative five and ten year survival was 63% and 42% respectively. Three patients developed either disease recurrence or metastases post-surgery. One patient developed deep infection requiring washout and suppressive antibiotics. No patients required revision surgery. The median MSTS score at last follow up was 66%. ConclusionsEPR of the distal tibia is a viable option and provides good function outcomes.

Current treatment of infected non-union after intramedullary nailing

Non-union is a devastating consequence of a fracture. Non-unions cause substantial patient morbidity with patients suffering from loss of function of the affected extremity, increased pain, and a substantial decrease in the quality of life. The management is often associated with repeated, unsuccessful operations resulting in prolonged hospital stays, which has social and economic consequences to both the patient and the healthcare system. The rates of non-union following intramedullary (IM) nailing vary according to anatomical location. There is currently no consensus regarding the treatment of infected non-unions following IM nailing, but the most common procedures reported are; exchange IM nail with antibiotic suppression or excision of the non-union, (stabilisation with external fixation or less commonly plate or IM nail) and then reconstruction of the bone defect with distraction osteogenesis or the Masquelet technique. This article explores the general principles of treatment, fixation modalities and proposes a treatment strategy for the management of infected non-unions following intramedullary nailing.

Pharmacotherapy for Non-Cystic Fibrosis Bronchiectasis: Results From an NTM Info & Research Patient Survey and the Bronchiectasis and NTM Research Registry

Non-cystic fibrosis bronchiectasis ("bronchiectasis") is a chronic inflammatory lung disease often associated with nontuberculous mycobacteria (NTM) infection. Very little data exist to guide bronchiectasis management decisions. We sought to describe patterns of inhaled corticosteroid (ICS) and antibiotic therapy in the United States. We invited 2,000 patients through NTM Info & Research (NTMir) to complete an anonymous electronic survey. We separately queried baseline clinical and laboratory data from the US Bronchiectasis and NTM Research Registry (BRR). Among 511 NTMir survey responders with bronchiectasis, whose median age was 67 years, 85 (17%) reported asthma and 99 (19%) reported COPD. History of ICS use was reported by 282 (55%), 171 (61%) of whom were treated 1 year or longer, and 150 (53%) were currently taking ICSs. Fewer reported ever taking azithromycin for non-NTM bronchiectasis (203 responders [40%]) or inhaled tobramycin (78 responders [15%]). The median age of 1,912 BRR patients was 69 years; 528 (28%) had asthma and 360 (19%) had COPD. Among 740 patients (42%) without NTM, 314 were taking ICSs at baseline. Among patients without NTM who were taking ICSs, only 178 (57%) had a concurrent diagnosis of COPD or asthma that could explain ICS use. Fewer were taking suppressive macrolides (96 patients [13%]), and of the 70 patients (10%) taking inhaled suppressive antibiotics, 48 (68%) had chronic Pseudomonas aeruginosa infection. ICS use was common in two national samples of patients with bronchiectasis, with relatively few patients taking suppressive antibiotic therapies. Further research is needed to clarify the safety and effectiveness of these therapies in patients with bronchiectasis.

Prolonged suppressive antibiotic therapy for prosthetic joint infection in the elderly: a national multicentre cohort study.

During prosthetic joint infection (PJI), optimal surgical management with exchange of the device is sometimes impossible, especially in the elderly population. Thus, prolonged suppressive antibiotic therapy (PSAT) is the only option to prevent acute sepsis, but little is known about this strategy. We aimed to describe the characteristics, outcome and tolerance of PSAT in elderly patients with PJI. We performed a national cross-sectional cohort study of patients>75years old and treated with PSAT for PJI. We evaluated the occurrence of events, which were defined as: (i) local or systemic progression of the infection (failure), (ii) death and (iii) discontinuation or switch of PSAT. A total of 136 patients were included, with a median age of 83years [interquartile range (IQR) 81-88]. The predominant pathogen involved was Staphylococcus (62.1%) (Staphylococcus aureus in 41.7%). A single antimicrobial drug was prescribed in 96 cases (70.6%). There were 46 (33.8%) patients with an event: 25 (18%) with an adverse drug reaction leading to definitive discontinuation or switch of PSAT, 8 (5.9%) with progression of sepsis and 13 died (9.6%). Among patients under follow-up, the survival rate without an event at 2years was 61% [95% confidence interval (CI): 51;74]. In the multivariate Cox analysis, patients with higher World Health Organization (WHO) score had an increased risk of an event [hazard ratio (HR)=1.5, p=0.014], whereas patients treated with beta-lactams are associated with less risk of events occurring (HR=0.5, p=0.048). In our cohort, PSAT could be an effective and safe option for PJI in the elderly.

MP23-09 PRACTICE PATTERNS ACROSS SPECIALTIES IN THE TREATMENT OF WOMEN WITH RECURRENT UTIS IN AN ACADEMIC HEALTHCARE SYSTEM

You have accessJournal of UrologyInfections/Inflammation/Cystic Disease of the Genitourinary Tract: Kidney & Bladder II1 Apr 2017MP23-09 PRACTICE PATTERNS ACROSS SPECIALTIES IN THE TREATMENT OF WOMEN WITH RECURRENT UTIS IN AN ACADEMIC HEALTHCARE SYSTEM Matthew Sterling, Eliza Lamin, Alexander Skokan, Alan Wein, and Ariana Smith Matthew SterlingMatthew Sterling More articles by this author , Eliza LaminEliza Lamin More articles by this author , Alexander SkokanAlexander Skokan More articles by this author , Alan WeinAlan Wein More articles by this author , and Ariana SmithAriana Smith More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.737AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Recurrent urinary tract infections (UTIs) are a common problem managed by a variety of medical specialties. Several treatment strategies exist and no evidence-based pathway of care has been established. The objective of this investigation is to better understand the practice patterns for managing patients with recurrent UTIs in a tertiary care healthcare system. METHODS A 17-question electronic survey regarding the management of recurrent UTIs in women was distributed to 210 providers in the Internal Medicine (IM), Family Medicine (FM), Ob-Gyn (OBG), and Urology departments. Recurrent UTIs was defined as =3 in 1 year. RESULTS A total of 68 (32.3%) providers completed the survey. Sixty percent (39/65) of providers report treating patients with recurrent UTIs with an extended course of antibiotics. Additionally, 35% (23/65) of providers treat despite lack of symptoms and 37% (24/65) of providers utilize suppressive antibiotics. OBG and Urologists utilize suppressive antibiotics more than IM and FM at 50%. Of those providing suppressive antibiotics, 79% (19/24) chose nitrofurantoin. Providers refer to specialists after trying a median of 3 courses of antibiotics (IQR 3-4). Referral to Urologists was most common for concomitant stones (88%, 51/58) or hydronephrosis (78%, 45/58), whereas referral to Infectious Disease (ID) was most common for bacterial resistance (75%, 51/68) or multiple patient allergies (48.5%, 33/68). Overall, 91.2% (62/68) of providers felt a protocol for evaluating and managing recurrent UTIs would be useful. CONCLUSIONS Practice patterns for managing recurrent UTIs in female patients vary across and within specialties within the same healthcare system. There is limited data to suggest extended courses of antibiotics are effective for recurrent UTIs and may potentially contribute to increasing susceptibility to infection, yet this strategy is commonly employed in our healthcare system. Although referral patterns differ between Urologists and ID specialists, multiple antibiotics are employed prior to referral. The majority of providers believe a written protocol would improve patient care, reducing variability and improving quality. © 2017FiguresReferencesRelatedDetailsCited bySmith A, Brown J, Wyman J, Berry A, Newman D and Stapleton A (2018) Treatment and Prevention of Recurrent Lower Urinary Tract Infections in Women: A Rapid Review with Practice RecommendationsJournal of Urology, VOL. 200, NO. 6, (1174-1191), Online publication date: 1-Dec-2018. Volume 197Issue 4SApril 2017Page: e296 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Matthew Sterling More articles by this author Eliza Lamin More articles by this author Alexander Skokan More articles by this author Alan Wein More articles by this author Ariana Smith More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Poor Outcomes of Irrigation and Debridement in Acute Periprosthetic Joint Infection With Antibiotic-Impregnated Calcium Sulfate Beads

BackgroundOne proposed strategy to increase the success of irrigation and debridement with implant retention for the treatment of acute periprosthetic joint infection (PJI) is the use of dissolvable antibiotic-impregnated calcium sulfate beads to provide a local depot of antibiotics. The purpose of this study was to evaluate the outcome of such an approach. MethodsThirty-two patients with acute hematogenous (18 patients; 1 bilateral) or acute postoperative (14 patients) PJIs who underwent irrigation and debridement with implant retention and addition of antibiotic-impregnated calcium sulfate beads were retrospectively reviewed. PJI followed 27 total knee arthroplasties and 6 total hip arthroplasties. The most common infecting organisms were methicillin-sensitive Staphylococcus aureus (13 of 33) and Streptococcus (9 of 33). The primary outcome parameter was recurrence of infection according to the Musculoskeletal Infection Society criteria. Patients were followed up for a minimum of 3 months or until failure. ResultsAt a mean of 12.7 months (range, 3-30 months), 16 of the 33 patients failed (48%). Acute hematogenous and acute postoperative PJI had similar failure rates at 47% and 50%, respectively (P = .88). Seven failures required a 2-stage exchange, while 8 patients were treated with chronic antibiotic suppression, being unwilling or unable to undergo further surgical intervention. ConclusionThe addition of antibiotic-impregnated calcium sulfate beads does not appear to improve outcomes of irrigation and debridement with implant retention in the setting of acute hematogenous or acute postoperative PJI. Given the short follow-up in this report, this represents a best-case scenario and the overall failure rate may be higher with further follow-up.

Treatment Challenges of Prosthetic Hip Infection with Associated Iliacus Muscle Abscess: Report of 5 Cases and Literature Review.

Prosthetic joint infection is an unfortunate though well-recognized complication of total joint arthroplasty. An iliacus and/or iliopsoas muscle abscess is a rarely documented presentation of hip prosthetic joint infection. It is thought an unrecognized retroperitoneal nidus of infection can be a source of continual seeding of the prosthetic hip joint, prolonging attempts to eradicate infection despite aggressive debridement and explant attempts. The current study presents five cases demonstrating this clinical scenario, and discusses various treatment challenges.In each case we report the patient's clinical history, pertinent imaging, management and outcome. Diagnosis of the iliacus muscle abscess was made using computed tomography imaging. In brief, the mean number of total drainage procedures (open and percutaneous) per patient was 4.2, and outcomes consisted of one patient with a hip girdlestone, two patients with delayed revisions, and two patients with retained prosthesis. All patients ended with functional pain and on oral antibiotic suppression with an average follow up of 18 months.This article highlights an iliacus muscle abscess as an unrecognized source of infection to a prosthetic hip. It demonstrates resilience to standard treatment protocols for prosthetic hip infection, and is associated with poor patient outcomes. Aggressive surgical debridement appears to remain critical to treatment success, and early retroperitoneal debridement of the abscess should be considered.

Erythematous plaques and papules on a premature infant

A 2240 gram boy was born at 33.2 weeks gestation with nonblanching, deeply erythematous plaques and papules on the back, flanks, and scalp (Figure 1). His mother was GBS positive and on antibiotic suppression for prior cutaneous MRSA and urinary tract infections. Intrapartum intravenous Penicillin G was administered, and the amniotic sac was artificially ruptured 4 hours prior to delivery to facilitate labor. The delivery was uncomplicated without concern for chorioamnionitis, but the patient initially required CPAP for respiratory distress with 1-minute and 5-minute Apgar scores of 7 and 8, respectively. A skin punch biopsy is shown (Figure 2).