151
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Epperson TM, Bennett KK, Kupiec KK, Speigel K, Neely SB, Resman-Targoff BH, Kinney KK, White BP. Impact of a Pharmacist-Managed Outpatient Parenteral Antimicrobial Therapy (OPAT) Service on Cost Savings and Clinical Outcomes at an Academic Medical Center. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e15. [PMID: 36714295 PMCID: PMC9879875 DOI: 10.1017/ash.2022.374] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 12/14/2022] [Accepted: 12/14/2022] [Indexed: 01/18/2023]
Abstract
Background Outpatient antimicrobial therapy (OPAT) is managed by a variety of teams, but primarily through an infectious disease clinic. At our medical center, OPAT monitoring is performed telephonically by pharmacists through a collaborative practice agreement under the supervision of an infectious disease physician. The effect of telephonic monitoring of OPAT by pharmacists on patient outcomes is unknown. Methods This retrospective cohort study was conducted between July 2017 and July 2018 at a 350-bed academic medical center and included adult patients discharged home on IV antibiotics or oral linezolid. The experimental group comprised patients discharged with a consultation for the OPAT management program, whereas the control group comprised patients discharged home without a consultation. The primary outcome was 30-day readmission. Results In total, 399 patients were included: 243 patients in the OPAT management program group and 156 patients in the control group. The 30-day readmission rates were similar in each cohort (20% vs 19%; P = .8193); however, the 30-day readmission rates were lower in the OPAT management program for patients discharged on vancomycin (19.4% vs 39.1%; P = .004). Conclusions We did not find a difference in 30-day readmissions between patients receiving pharmacy-driven OPAT management services and those who did not. Patients receiving vancomycin via OPAT had lower 30-day readmissions when included in the pharmacist-driven OPAT management program. Institutions with limited resources may consider reserving OPAT management services for patients receiving antimicrobials that require pharmacokinetic dosing and/or close monitoring.
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Affiliation(s)
| | - Kiya K. Bennett
- Clinical and Administrative Sciences, Department of Pharmacy, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma
| | - Katherine K. Kupiec
- Department of Pharmacy, University of Oklahoma Medical Center, Oklahoma City, Oklahoma
| | - Kathy Speigel
- Department of Nursing, University of Oklahoma Medical Center, Oklahoma City, Oklahoma
| | - Stephen B. Neely
- Clinical and Administrative Sciences, Department of Pharmacy, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma
| | - Beth H. Resman-Targoff
- Clinical and Administrative Sciences, Department of Pharmacy, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma
| | - Karen K. Kinney
- Infectious Diseases Section, Department of Internal Medicine, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Bryan P. White
- Department of Pharmacy, University of Oklahoma Medical Center, Oklahoma City, Oklahoma
- Infectious Diseases Section, Department of Internal Medicine, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
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152
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Yang WT, Dombrowski JC, Glick SN, Kim HN, Beieler AM, Lan KF, Dhanireddy S. Partial-Oral Antibiotic Therapy for Bone and Joint Infections in People With Recent Injection Drug Use. Open Forum Infect Dis 2023; 10:ofad005. [PMID: 36726538 PMCID: PMC9887258 DOI: 10.1093/ofid/ofad005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/05/2023] [Indexed: 01/09/2023] Open
Abstract
Background Limited outcome data exist regarding partial-oral antibiotic therapy, defined as oral antibiotics as part of a patient's treatment, for bone and joint infections (BJIs) in people who inject drugs (PWID). Methods We conducted a retrospective study of all PWID reporting drug use within 3 months and BJIs requiring ≥6 weeks of antibiotics in an urban safety-net hospital between February 1, 2019, and February 1, 2021. Treatment outcomes were assessed by chart review. Rates of failure, defined as death, symptoms, or signs concerning for worsening or recurrent infections, were assessed 90 and 180 days after completion of antibiotics. Univariate logistic regression was used to explore the association between covariates and failure. Results Of 705 patients with BJI, 88 (13%) were PWID. Eighty-six patients were included in the final cohort. Forty-four (51%) were homeless, 50 (58%) had spine infection, 68 (79%) had surgery, and 32 of 68 (47%) had postoperatively retained hardware. Twelve (14%) of 86 patients received exclusively intravenous (IV) antibiotics, and 74 (86%) received partial-oral antibiotics. Twelve (14%) of 86 patients had patient-directed discharge. In those who received partial-oral antibiotics, the failure rate was 20% at 90 days and 21% at 180 days after completion of intended treatment. Discharge to a medical respite and follow-up with infectious diseases (ID) or surgery were negatively associated with odds of failure. Conclusions Partial-oral treatment of BJI in PWID was a common practice and often successful when paired with medical respite and follow-up with ID or surgery.
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Affiliation(s)
- Wei-Teng Yang
- Correspondence: Wei-Teng Yang, MD, MPH, Section of Addiction Medicine, Division of General Internal Medicine and Geriatrics, Department of Medicine, Oregon Health & Science University, 3181 Southwest Samuel Jackson Park Road, Mail Code UNH30, Portland, OR 97239. E-mail:
| | - Julia C Dombrowski
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA,HIV/STD Program, Public Health-Seattle & King County, Seattle, Washington, USA
| | - Sara N Glick
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA,HIV/STD Program, Public Health-Seattle & King County, Seattle, Washington, USA
| | - H Nina Kim
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | | | - Kristine F Lan
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
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153
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Pertzborn M, Rivera CG, Tai DBG. Taking the route less traveled: on the way to COpAT. Ther Adv Infect Dis 2023; 10:20499361231192771. [PMID: 37600977 PMCID: PMC10433885 DOI: 10.1177/20499361231192771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 07/20/2023] [Indexed: 08/22/2023] Open
Abstract
Antimicrobial therapy is an essential practice within medicine. Over the last 4 years, complex outpatient antimicrobial therapy (COpAT) with oral antimicrobials has become a rapidly developing area of practice and is non-inferior to outpatient parenteral antimicrobial therapy (OPAT) in certain infectious syndromes. Currently, the available literature does not describe the implementation of oral antimicrobials within the current outpatient antimicrobial therapy process. Throughout this article, the authors present a review of current literature, a proposed definition of COpAT and offer methods readers can utilize to implement an integrated COpAT/OPAT program with oral antimicrobial-specific monitoring within their current practice.
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Affiliation(s)
- Margaret Pertzborn
- Department of Pharmacy, Mayo Clinic Health System, 1400 Bellinger Street, Eau Claire, WI 54702-1510, USA
| | | | - Don Bambino Geno Tai
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA
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154
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Minotti C, Tirelli F, Guariento C, Sturniolo G, Giaquinto C, Da Dalt L, Zulian F, Meneghel A, Martini G, Donà D. Impact of guidelines implementation on empiric antibiotic treatment for pediatric uncomplicated osteomyelitis and septic arthritis over a ten-year period: Results of the ELECTRIC study (ostEomyeLitis and sEptiC arThritis tReatment in children). Front Pediatr 2023; 11:1135319. [PMID: 36911022 PMCID: PMC9997840 DOI: 10.3389/fped.2023.1135319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 01/30/2023] [Indexed: 02/25/2023] Open
Abstract
Background Due to the growing evidence of the efficacy of intravenous (IV) cefazolin with an early switch to oral cefalexin in uncomplicated pediatric osteomyelitis (OM) and septic arthritis (SA) in children, we changed our guidelines for empiric antibiotic therapy in these conditions. This study aims at evaluating the impact of the guidelines' implementation in reducing broad-spectrum antibiotic prescriptions, duration of IV antibiotic treatment and hospital stay, treatment failure and recurrence. Materials and methods This is a retrospective, observational, quasi-experimental study. The four years pre-intervention were compared to the six years, ten months post-intervention (January 2012, through December 2015; January 2016, through October 31st, 2022). All patients aged 3 months to 18 years with OM or SA were evaluated for inclusion. Each population was divided into three groups: pre-intervention, post-intervention not following the guidelines, and post-intervention following the guidelines. Differences in antibiotic prescriptions such as Days of Therapy (DOT), activity spectrum and Length of Therapy (LOT), length of hospital stay (LOS), broad-spectrum antibiotics duration (bsDOT), treatment failure and relapse at six months were analyzed as outcomes. Results Of 87 included patients, 48 were diagnosed with OM (8 pre-intervention, 9 post-intervention not following the guidelines and 31 post-intervention following the guidelines) and 39 with SA (9 pre-intervention, 12 post-intervention not following the guidelines and 18 post-intervention following the guidelines). In OM patients, IV DOT, DOT/LOT ratio, and bsDOT were significantly lower in the guidelines group, with also the lowest proportion of patients discharged on IV treatment. Notably, significantly fewer cases required surgery in the post-intervention groups. Considering SA, LOS, IV DOT, DOT/LOT ratio, and bsDOT were significantly lower in the guidelines group. The treatment failure rate was comparable among all groups for both OM and SA. There were no relapse cases. The overall adherence was between 72 and 100%. Conclusions The implementation of guidelines was effective in decreasing the extensive use of broad-spectrum antibiotics and combination therapy for both OM and SA. Our results show the applicability, safety, and efficacy of a narrow-spectrum IV empirical antibiotic regimen with cefazolin, followed by oral monotherapy with first/second-generation cephalosporins, which was non-inferior to broad-spectrum regimens.
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Affiliation(s)
- Chiara Minotti
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Francesca Tirelli
- Pediatric Rheumatology Unit, Department of Women's and Children's Health, University of Padua, Padua, Italy.,Pediatric Emergency Department, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Chiara Guariento
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Giulia Sturniolo
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Carlo Giaquinto
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Liviana Da Dalt
- Pediatric Emergency Department, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Francesco Zulian
- Pediatric Rheumatology Unit, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Alessandra Meneghel
- Pediatric Rheumatology Unit, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Giorgia Martini
- Pediatric Rheumatology Unit, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Daniele Donà
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padua, Padua, Italy
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155
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Kwon HK, Yu KE, Lee FY. Construction and evaluation of a clinically relevant model of septic arthritis. Lab Anim (NY) 2023; 52:11-26. [PMID: 36564668 DOI: 10.1038/s41684-022-01089-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 11/03/2022] [Indexed: 12/24/2022]
Abstract
Despite the creation of several experimental animal models for the study of septic arthritis, a protocol detailing the development of a reliable and easily reproducible animal model has not yet been reported. The experimental protocol described herein for the development of a clinically relevant mouse model of septic arthritis includes two main study stages: the first stage consisting of the preparation of the mice and of the methicillin-resistant Staphylococcus aureus (MRSA) cultures, followed by direct inoculation of MRSA into the knee joints of C57BL/6J mice (25-40 min); and a second study stage consisting of multiple sample collection and data analysis (1-3 days). This protocol may be carried out by researchers skilled in mouse care and trained to work with biosafety-level-2 agents such as MRSA. The model of septic arthritis described here has demonstrated clinical relevance in developing intra-articular inflammation and cartilage destruction akin to that of human patients. Moreover, we describe methods for serum, synovial fluid and knee joint tissue analysis that were used to confirm the development of septic arthritis in this model, and to test potential treatments. This protocol confers the advantages of enabling granular evaluation of the pathophysiology of MRSA infection and of the efficacy of therapeutic medications; it may also be employed to study a range of native joint diseases beyond inflammatory pathologies alone.
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Affiliation(s)
- Hyuk-Kwon Kwon
- Department of Orthopaedics and Rehabilitation, Yale University, School of Medicine, New Haven, CT, USA
| | - Kristin E Yu
- Department of Orthopaedics and Rehabilitation, Yale University, School of Medicine, New Haven, CT, USA
| | - Francis Y Lee
- Department of Orthopaedics and Rehabilitation, Yale University, School of Medicine, New Haven, CT, USA.
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156
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Muacevic A, Adler JR, Skedros JG. Schaalia (Formerly Actinomyces) turicensis Infection Following Open Rotator Cuff Repair. Cureus 2023; 15:e34242. [PMID: 36852356 PMCID: PMC9964717 DOI: 10.7759/cureus.34242] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2023] [Indexed: 01/27/2023] Open
Abstract
We report the case of a male in his early 70s who developed a deep infection after an open rotator cuff repair, with Schaalia turicensis as the only organism isolated from a surgical biopsy of the tendon remnants and phlegmatic/purulent material at the failed repair site. This species was originally within the genus Actinomyces. We report this case because it is the only one that we could locate where an infected open rotator cuff repair site grew S. turicensis. Our patient was not diabetic, did not smoke, and did not have other recent or concurrent infections. He had hypertension, hypothyroidism, depression, and a hyperactive bladder. Hence, he only had minor risk factors for infection. His postoperative shoulder infection was eradicated with surgical irrigation and debridement, and 6.5 weeks of primarily oral antibiotic treatment. We also review the literature on infections after any shoulder surgery where Schaalia or Actinomyces species were isolated.
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157
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Bradley AC, Wingler MJB, Artman KL, Ward LM, Lucar J. An evaluation of risk factors for readmission in patients receiving outpatient parenteral antimicrobial therapy. Ther Adv Infect Dis 2023; 10:20499361231195966. [PMID: 37667754 PMCID: PMC10475225 DOI: 10.1177/20499361231195966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 08/02/2023] [Indexed: 09/06/2023] Open
Abstract
Background Outpatient parenteral antimicrobial therapy (OPAT), when required, is beneficial to patients and healthcare systems by reducing hospital length-of-stay, providing cost savings, and improving patient satisfaction. Objectives The purpose of this study is to determine readmission rates and associated risk factors in patients receiving OPAT at home. Methods This retrospective study included hospitalized patients 15 years and older who were discharged on intravenous antimicrobial therapy via OPAT at home between January 2018 and December 2019. Patients receiving antimicrobials at a skilled nursing facility, long-term acute care, or dialysis center, and those who began OPAT at home directly from the outpatient setting were excluded. The primary outcome of this study was all-cause 30-day readmission rate. Secondary outcomes included 90-day readmission rate, rates of complications related to OPAT, emergency department visits during OPAT, and predictors of all-cause 30-day readmission through a logistic regression analysis. Results Two hundred individual patients were included in the analysis; 60% were male and the mean age was 49 years. The most common indications for OPAT at home were bone and joint infection (52%) and bacteremia (26%). Forty patients (20%) experienced an unplanned, all-cause 30-day readmission, with a total of 48 readmission events. Of the 40 patients who were readmitted within 30 days, 20 (50%) were due to non-OPAT related reasons. Sixty patients (30%) experienced an OPAT-related complication, and chronic kidney disease was found to be an independent predictor of readmission (OR: 2.8, 95% CI: 1.0-7.6). Conclusions Patients receiving OPAT at home are at increased risk for early hospital readmission, but it is often due to reasons not associated with OPAT. Patients with chronic kidney disease beginning OPAT at home should be closely monitored after discharge.
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Affiliation(s)
- Abby C. Bradley
- Department of Pharmacy, University of Mississippi Medical Center, Jackson, MS, USA
- Department of Pharmacy, Ascension St. Vincent’s East, Birmingham, AL, USA
| | - Mary Joyce B. Wingler
- Department of Antimicrobial Stewardship, University of Mississippi Medical Center, 2500 N State Street, Jackson, MS 39216-4505, USA
| | - Katherine L. Artman
- Department of Pharmacy, University of Mississippi Medical Center, Jackson, MS, USA
| | - Lori M. Ward
- Department of Population Health Science, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jose Lucar
- Division of Infectious Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
- Division of Infectious Diseases, Department of Medicine, The George Washington University, Washington, DC, USA
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158
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He SY, Yu B, Jiang N. Current Concepts of Fracture-Related Infection. Int J Clin Pract 2023; 2023:4839701. [PMID: 37153693 PMCID: PMC10154639 DOI: 10.1155/2023/4839701] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 01/24/2023] [Accepted: 04/08/2023] [Indexed: 05/10/2023] Open
Abstract
Currently, fracture-related infection (FRI) still represents great challenges in front of orthopaedic surgeons, despite great advances that have been achieved regarding its diagnosis and treatment. Although both FRI and prosthetic joint infection (PJI) belong to osteoarticular infections and share similarities, FRI displays unique characteristics. Diagnosis of FRI is sometimes difficult owing to the nonspecific symptoms, and treatment is usually tricky, with a high risk of infection recurrence. In addition, the long disease course is associated with a significantly elevated risk of disability, both physically and psychologically. Moreover, such a disorder still poses heavy economic burdens to the patients, both personally and socially. Therefore, early diagnosis and reasonable treatment are the key issues for increasing the cure rate, decreasing the risks of infection relapse and disability, and improving the life quality and prognosis of the patients. In this review, we summarized the present concepts regarding the definition, epidemiology, diagnosis, and treatment of FRI.
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Affiliation(s)
- Si-ying He
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Southern Medical University Nanfang Hospital, Guangzhou 510515, China
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Southern Medical University Nanfang Hospital, Guangzhou 510515, China
| | - Bin Yu
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Southern Medical University Nanfang Hospital, Guangzhou 510515, China
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Southern Medical University Nanfang Hospital, Guangzhou 510515, China
| | - Nan Jiang
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Southern Medical University Nanfang Hospital, Guangzhou 510515, China
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Southern Medical University Nanfang Hospital, Guangzhou 510515, China
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159
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Impact of specialty on the self-reported practice of using oral antibiotic therapy for definitive treatment of bloodstream infections. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2023; 3:e48. [PMID: 36970426 PMCID: PMC10031584 DOI: 10.1017/ash.2023.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/02/2023] [Accepted: 02/03/2023] [Indexed: 03/11/2023]
Abstract
Abstract
Background:
No established guidelines exist regarding the role of oral antibiotic therapy (OAT) to treat bloodstream infections (BSIs), and practices may vary depending on clinician specialty and experience.
Objective:
To assess practice patterns regarding oral antibiotic use for treatment of bacteremia in infectious diseases clinicians (IDCs, including physicians and pharmacists and trainees in these groups) and non–infectious diseases clinicians (NIDCs).
Design:
Open-access survey.
Participants:
Clinicians caring for hospitalized patients receiving antibiotics.
Methods:
An open-access, web-based survey was distributed to clinicians at a Midwestern academic medical center using e-mail and to clinicians outside the medical center using social media. Respondents answered questions regarding confidence prescribing OAT for BSI in different scenarios. We used χ2 analysis for categorical data evaluated association between responses and demographic groups.
Results:
Of 282 survey responses, 82.6% of respondents were physicians, 17.4% pharmacists, and IDCs represented 69.2% of all respondents. IDCs were more likely to select routine use of OAT for BSI due to gram-negative anaerobes (84.6% vs 59.8%; P < .0001), Klebsiella spp (84.5% vs 69.0%; P < .009), Proteus spp (83.6% vs 71.3%; P < .027), and other Enterobacterales (79.5% vs 60.9%; P < .004). Our survey results revealed significant differences in selected treatment of Staphylococcus aureus syndromes. Fewer IDCs than NIDCs selected OAT to complete treatment for methicillin-resistant S. aureus (MRSA) BSI due to gluteal abscess (11.9% vs 25.6%; P = .012) and methicillin-susceptible S. aureus (MSSA) BSI due to septic arthritis (13.9% vs 20.9%; P = .219).
Conclusions:
Practice variation and discordance with evidence for the use of OAT for BSIs exists among IDCs versus NIDCs, highlighting opportunities for education in both clinician groups.
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160
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Davar K, Clark D, Centor RM, Dominguez F, Ghanem B, Lee R, Lee TC, McDonald EG, Phillips MC, Sendi P, Spellberg B. Can the Future of ID Escape the Inertial Dogma of Its Past? The Exemplars of Shorter Is Better and Oral Is the New IV. Open Forum Infect Dis 2022; 10:ofac706. [PMID: 36694838 PMCID: PMC9853939 DOI: 10.1093/ofid/ofac706] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 12/28/2022] [Indexed: 12/31/2022] Open
Abstract
Like all fields of medicine, Infectious Diseases is rife with dogma that underpins much clinical practice. In this study, we discuss 2 specific examples of historical practice that have been overturned recently by numerous prospective studies: traditional durations of antimicrobial therapy and the necessity of intravenous (IV)-only therapy for specific infectious syndromes. These dogmas are based on uncontrolled case series from >50 years ago, amplified by the opinions of eminent experts. In contrast, more than 120 modern, randomized controlled trials have established that shorter durations of therapy are equally effective for many infections. Furthermore, 21 concordant randomized controlled trials have demonstrated that oral antibiotic therapy is at least as effective as IV-only therapy for osteomyelitis, bacteremia, and endocarditis. Nevertheless, practitioners in many clinical settings remain refractory to adopting these changes. It is time for Infectious Diseases to move beyond its history of eminent opinion-based medicine and truly into the era of evidenced-based medicine.
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Affiliation(s)
- Kusha Davar
- Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, California, USA
| | - Devin Clark
- Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, California, USA
| | - Robert M Centor
- Department of Medicine, Birmingham Veterans Affairs (VA) Medical Center, Birmingham, Alabama, Birmingham, Alabama, USA
| | - Fernando Dominguez
- Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, California, USA
| | | | - Rachael Lee
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University, Montreal, Canada
| | - Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Matthew C Phillips
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA
| | - Parham Sendi
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Brad Spellberg
- Correspondence: Brad Spellberg, MD, Hospital Administration, 2051 Marengo Street, Los Angeles, CA 90033 ()
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161
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Evans TJ, Jawad S, Kalyal N, Nadarajah A, Amarouche M, Stapleton S, Ward C, Breathnach A. Retrospective review of the epidemiology, microbiology, management and outcomes of intra-cranial abscesses at a neurosurgical tertiary referral centre, 2018-2020. Ann Clin Microbiol Antimicrob 2022; 21:58. [PMID: 36575518 PMCID: PMC9795649 DOI: 10.1186/s12941-022-00550-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 12/09/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Intracranial abscesses are rare but serious, and are associated with significant morbidity and mortality. Due to both the rarity and severity of these infections, well-controlled trials have not been reported in the literature, and optimal management is a matter for expert opinion. Advances in surgical management have improved outcomes and increased rates of microbiological diagnosis. However, the approach to antimicrobial chemotherapy varies considerably, including the choice of antibiotic, the duration of treatment, and the timing of oral switch. METHODS We conducted a retrospective review of 43 cases of intracranial abscesses from a large, tertiary neurosurgical centre in London, UK, between 2018 and 2020, including 29 primary intra-parenchymal abscesses, 11 subdural abscesses and 3 extradural abscesses. RESULTS The majority of cases had surgical intervention; 6/43 (14%) required repeat intervention (all intra-parenchymal abscesses). A microbiological diagnosis was made in 83% of cases. Intravenous antibiotics were given for a median of 33 days (IQR 23-44 days), with a variable duration of oral follow-on antibiotics. Total duration of antibiotic treatment ranged from 0 to 467 days. Only three patients from our cohort are known to have died. CONCLUSION Shorter courses of intravenous antibiotics for brain abscesses were not associated with increased mortality. In the absence of well-controlled trials, a national registry of intracranial abscesses would provide invaluable data to inform optimal treatment.
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Affiliation(s)
- Terry John Evans
- grid.451349.eSt George’s University Hospitals NHS Foundation Trust, London, UK
| | - Sarah Jawad
- grid.451349.eSt George’s University Hospitals NHS Foundation Trust, London, UK
| | - Nida Kalyal
- grid.451349.eSt George’s University Hospitals NHS Foundation Trust, London, UK
| | - Angelina Nadarajah
- grid.451349.eSt George’s University Hospitals NHS Foundation Trust, London, UK
| | - Meriem Amarouche
- grid.451349.eSt George’s University Hospitals NHS Foundation Trust, London, UK
| | - Simon Stapleton
- grid.451349.eSt George’s University Hospitals NHS Foundation Trust, London, UK
| | - Christopher Ward
- grid.451349.eSt George’s University Hospitals NHS Foundation Trust, London, UK
| | - Aodhan Breathnach
- grid.451349.eSt George’s University Hospitals NHS Foundation Trust, London, UK
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Weng B, Oskooilar Y, Zakhary B, Chiu CA, Wu P, Mulligan N, Sutjita M. Evaluating Predictive Value of Surgical Resected Proximal Bone Margins in Diabetic Foot Osteomyelitis With Clinical Outcomes at 1 Year. Open Forum Infect Dis 2022; 10:ofac689. [PMID: 36632419 PMCID: PMC9830536 DOI: 10.1093/ofid/ofac689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 12/23/2022] [Indexed: 12/28/2022] Open
Abstract
Background Osteomyelitis of the diabetic foot remains a significant complication that may result in the need for amputation. Proximal surgical margin histopathology after limb-sparing amputation could be used to guide antimicrobial duration and prognostic management but remains debatable. Here we evaluate if negative proximal bone margins predict outcomes of diabetic foot osteomyelitis at 1 year. Methods A retrospective study assessed adults with diabetes undergoing limb-sparing foot amputations from September 2016 to September 2019. Patients required histopathology confirmation of osteomyelitis, proximal margin histopathology report, and documented electronic medical record follow-up through 12 months. The primary outcome evaluated if no further amputation at the same site was required in the following 12 months. Results Of 92 patients, 57 (61.9%) had pathology-confirmed negative margins for osteomyelitis. Patients with negative margins required less frequent subsequent amputations at the same site within 12 months compared to positive margins (86.0% vs 65.7%; P = .003). Antibiotic duration was shorter in patients with negative margins (mean, 18 vs 30 days; P = .001). Negative-margin patients also noted lower rates of readmission at 12 months (26.3% vs 51.4%; P = .015) for site-specific complications. Staphylococcus aureus was more predominant in patients with positive versus negative margins (57.1% vs 29.8%; P = .017). Conclusions Negative proximal bone margin by histopathology was associated with lower frequency of further amputations at the index surgical site within 12 months. This group also received shorter courses of antibiotic therapy. It was also associated with lower rates of readmission at 12 months for surgical-site complications. Proximal margin histopathology results potentially can be integrated to guide antimicrobial duration and decrease the frequency of further amputation at the original site.
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Affiliation(s)
- Bruce Weng
- Correspondence: Bruce Weng, DO, Infectious Disease - Department of Internal Medicine, Riverside University Health System, 26520 Cactus Ave, Moreno Valley, CA 92555, USA ()
| | - Yasmin Oskooilar
- Department of Internal Medicine, University of California, Riverside, California, USA
| | - Bishoy Zakhary
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System, Moreno Valley, California, USA
| | - Chiao An Chiu
- Department of Pharmacy, Riverside University Health System, Moreno Valley, California, USA
| | - Patrick Wu
- Division of Infectious Diseases, Department of Internal Medicine, Riverside University Health System, Moreno Valley, California, USA
- Department of Internal Medicine, University of California, Riverside, California, USA
| | - Nikki Mulligan
- Department of Pharmacy, Riverside University Health System, Moreno Valley, California, USA
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163
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Prada C, Bengoa F, Bhandari M. The management of fracture related infections: What practices can be supported by high-level evidence? J Orthop Surg (Hong Kong) 2022; 30:10225536221119580. [PMID: 36545907 DOI: 10.1177/10225536221119580] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Fracture related infections (FRIs) are a disabling condition causing significant concern within the orthopaedic community. FRIs have a huge societal and economic burden leading to prolonged recovery times and the potential for becoming chronic conditions or being life-threatening. Despite its importance in our field, the surgical community has just recently agreed on a definition which, added to the lack of surgical trials assessing preventive and treatment interventions have limited our understanding and precipitated wide variations in surgeons' practice. This article aims to review the current practices that can be supported with high-quality evidence. Currently, we have a limited body of high-quality evidence on FRI prevention and treatment. A handful of measures have proven effective, such as the use of prophylactic antibiotics, the use of saline and low pressure as the preferred irrigation solution and the safety of delaying initial surgical débridement more than 6 hours without impacting infection rates for open fracture wounds débridement. Future multicentre trials, properly powered, will shed light on current areas of controversy regarding the benefit of different preoperative and perioperative factors for the prevention and treatment of FRIs. Higher quality evidence is needed to guide surgeons to offer an evidence-based approach to prevent FRI occurrence and to treat patients suffering from them.
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Affiliation(s)
- Carlos Prada
- Division of Orthopaedic Surgery, Department of Surgery, 3710McMaster University, Hamilton, Ontario, Canada
| | - Francisco Bengoa
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mohit Bhandari
- Division of Orthopaedic Surgery, Department of Surgery, 3710McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, 3710McMaster University, Hamilton, Ontario, Canada
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164
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Valderrama-Molina CO, Pesántez R. Fracture-Related infection - the role of the surgeon and surgery in prevention and treatment. J Orthop Surg (Hong Kong) 2022; 30:10225536221118520. [PMID: 36545936 DOI: 10.1177/10225536221118520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Fracture-related infection (FRI) is a complication that impacts care costs, quality of life, and patient function. Great strides have been made in the last decade to obtain a common language for definition and diagnosis with the contribution of the Fracture-Related Infection Consensus. Although FRI treatment requires the participation of clinical specialists in infectious diseases for the management of antibiotics, it is necessary to understand that this complication is an eminently surgical pathology. The orthopedic surgeon must play a leadership role in the prevention and treatment of this complex disease. In this review, the most relevant aspects of prevention are updated, and a strategy for a sequential and comprehensive approach to the patient with this complication is presented.
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Affiliation(s)
| | - Rodrigo Pesántez
- Department of Orthopedics and Traumatology, 173061Fundación Santa Fe de Bogotá, Bogotá, Colombia
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165
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Pre-Referral Microbiology in Long Bone Infection: What Can It Tell Us? Antibiotics (Basel) 2022; 12:antibiotics12010013. [PMID: 36671214 PMCID: PMC9854536 DOI: 10.3390/antibiotics12010013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 12/18/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Background: It remains unclear how accurately patients’ previous microbiology correlates with that ascertained from deep sampling in long bone infection. This study assessed the quality of microbiology referral information and compared it to the gold standard of intra-operative deep tissue sampling. Methods: All patients referred to a single specialist centre within the UK between January 2019 and March 2020 who received surgery for long bone infection were eligible for inclusion. Data on microbiological testing that was performed prior to referral was collected prospectively at the time of clinic appointment and prior to surgery. Pre-referral microbiology was compared to microbiology from deep tissue samples taken during surgery. Results: 141 patients met the diagnostic criteria for long bone infection and were included for analysis. Of these, 72 patients had microbiological information available at referral from 88 samples, obtained from either sinus swab (n = 40), previous surgical sampling (n = 25), biopsy (n = 19) or blood cultures (n = 4). In 65.9% of samples, pre-referral microbiology was deemed to be a non-match when compared to intra-operative samples. Factors that increased risk of a non-match included presence of a sinus (odd’s ratio (OR) 11.3 [95% CI 2.84−56.6], p = 0.001), increased duration of time from sampling (OR 2.29, [95% CI 1.23−5.90], p = 0.030) and results from prior surgical sampling (OR 23.0 [95% CI 2.80−525.6], p = 0.011). Furthermore, previous surgical debridement gave an increased risk of multi-, extensively or pan-resistant isolates cultured from intra-operative sampling (OR 3.6 [95% CI 1.5−8.7], p < 0.01). Conclusions: We have demonstrated that presence of a sinus, a long time from the sample being taken and results from prior surgical sampling are more likely to give inaccurate representation of current microbiology. Importantly, in cases with previous debridement surgery, there was an increased risk of multi drug resistant isolates which should be planned for in future treatments.
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166
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Liu Y, Zhao Q, Chen C, Wu C, Ma Y. β-tricalcium phosphate/gelatin composite scaffolds incorporated with gentamycin-loaded chitosan microspheres for infected bone defect treatment. PLoS One 2022; 17:e0277522. [PMID: 36480529 PMCID: PMC9731412 DOI: 10.1371/journal.pone.0277522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 10/31/2022] [Indexed: 12/13/2022] Open
Abstract
The repair of infected bone defects remains a clinical challenge. Staphylococcus aureus is a common pathogenic micro-organism associated with such infections. Gentamycin (GM) is a broad spectrum antibiotic that can kill S. aureus in a dose-dependent manner. However, the systemic administration of antibiotics may lead to drug resistance and gut dysbiosis. In this work, we constructed β-tricalcium phosphate/gelatin composite scaffolds incorporated with gentamycin-loaded chitosan microspheres (CMs(GM)-β-TCP/gelatin composite scaffolds), which helped optimize the local GM release in the infected defect areas and enhance bone regeneration. The cumulative release curves showed that both microspheres and composite scaffolds reached a sustained slow-release phase after the initial rapid release, and the latter further stabilized the initial drug release rate. The release curve of CMs(GM)-β-TCP/gelatin composite scaffolds reached a plateau after 24 h, and the cumulative release reached 41.86% during this period. Moreover, the combination of β-TCP and gelatin mimicked bone composition and were able to provide the requisite mechanical strength (0.82 ± 0.05 MPa) during the first phase of bone generation. The inner structure of the scaffold was arranged in the shape of interconnected pores, and presented a porosity level of 16%. The apertures were uniform in size, which was beneficial for cell proliferation and material transportation. Macroscopic observation and histological analysis showed that CMs(GM)-β-TCP/gelatin composite scaffolds fused with bone tissues, and new tissues were formed in defect areas without any infection. This new composite scaffold may be a promising repair material for treating infected bone defects.
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Affiliation(s)
- Yu Liu
- Department of Orthopedics, Hospital of Zhejiang People’s Armed Police (PAP), Hangzhou, Zhejiang, China
| | - Qingqing Zhao
- Zhejiang Zhongwei Medical Research Center, Hangzhou, Zhejiang, China
| | - Changsong Chen
- Department of Orthopedics, Hospital of Zhejiang People’s Armed Police (PAP), Hangzhou, Zhejiang, China
| | - Chunhu Wu
- Department of Orthopedics, Hospital of Zhejiang People’s Armed Police (PAP), Hangzhou, Zhejiang, China
| | - Yuhai Ma
- Department of Orthopedics, Hospital of Zhejiang People’s Armed Police (PAP), Hangzhou, Zhejiang, China,* E-mail:
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167
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Pham TT, Andrey DO, Stampf S, Burkhard SH, Hirzel C, Tschopp J, Ullrich K, Strahm C, Schreiber PW, Boillat-Blanco N, Garzoni C, Khanna N, Manuel O, Mueller NJ, Suva D, van Delden C, Uçkay I, Neofytos D. Epidemiology and outcomes of bone and joint infections in solid organ transplant recipients. Am J Transplant 2022; 22:3031-3046. [PMID: 36031963 PMCID: PMC10087422 DOI: 10.1111/ajt.17184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 08/23/2022] [Accepted: 08/24/2022] [Indexed: 01/25/2023]
Abstract
Bone and joint infection (BJI) epidemiology and outcomes in solid organ transplant recipients (SOTr) remain largely unknown. We aim to describe BJI in a multi-center cohort of SOTr (Swiss Transplant Cohort Study). All consecutive SOTr with BJI (01.05.2008-31.12.2019) were included. A nested case-control study to identify risk factors for BJI was performed. Among 4482 patients, 61 SOTr with 82 BJI were included, at an incidence of 1.4% (95% CI 1.1-1.7), higher in heart and kidney-pancreas SOTr (Gray's test p < .01). Although BJI were predominately late events (median of 18.5 months post-SOT), most infections occurred during the first year post-transplant in thoracic SOTr. Diabetic foot osteomyelitis was the most frequent infection (38/82, 46.3%), followed by non-vertebral osteomyelitis (26/82, 31.7%). Pathogens included Gram-positive cocci (70/131, 53.4%), Gram-negative bacilli (34/131, 26.0%), and fungi (9/131, 6.9%). BJI predictors included male gender (OR 2.94, 95% CI 1.26-6.89) and diabetes (OR 2.97, 95% CI 1.34-6.56). Treatment failure was observed in 25.9% (21/81) patients and 1-year mortality post-BJI diagnosis was 14.8% (9/61). BJI remain a rare event in SOTr, associated with subtle clinical presentations, high morbidity and relapses, requiring additional studies in the future.
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Affiliation(s)
- Truong-Thanh Pham
- Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland.,Division of Orthopaedics and Trauma Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - Diego O Andrey
- Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Susanne Stampf
- Clinic for Transplantation Immunology and Nephrology (Swiss Transplant Cohort Study), University Hospital of Basel, Basel, Switzerland
| | - Sara H Burkhard
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Cédric Hirzel
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Johnathan Tschopp
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Kathrin Ullrich
- Division of Infectious Diseases and Hospital Epidemiology, University and University Hospital of Basel, Basel, Switzerland
| | - Carol Strahm
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Peter W Schreiber
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Noémie Boillat-Blanco
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Christian Garzoni
- Departments of Internal Medicine and Infectious Disease, Clinica Luganese, Lugano, Switzerland
| | - Nina Khanna
- Division of Infectious Diseases and Hospital Epidemiology, University and University Hospital of Basel, Basel, Switzerland
| | - Oriol Manuel
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Transplantation Center, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Nicolas J Mueller
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Domizio Suva
- Division of Orthopaedics and Trauma Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - Christian van Delden
- Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland.,Transplant Infectious Diseases Unit, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Ilker Uçkay
- Infectious Diseases, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Dionysios Neofytos
- Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland.,Transplant Infectious Diseases Unit, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
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168
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Cheng Y, Zhang Y, Zhao Z, Li G, Li J, Li A, Xue Y, Zhu B, Wu Z, Zhang X. Guanidinium-Decorated Nanostructure for Precision Sonodynamic-Catalytic Therapy of MRSA-Infected Osteomyelitis. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2022; 34:e2206646. [PMID: 36245331 DOI: 10.1002/adma.202206646] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 09/23/2022] [Indexed: 06/16/2023]
Abstract
Osteomyelitis caused by methicillin-resistant Staphylococcus aureus (MRSA) biofilm infection is difficult to eradicate and can even be life-threatening. Given that the infection is persistent and deep-seated in the bone tissue, controlled and efficient treatment of osteomyelitis remains challenging. Herein, an activatable nanostructure (Au/TNT@PG) is presented for synergistic sonodynamic-catalytic therapy of MRSA-infected osteomyelitis. The Au/TNT@PG backbone is obtained by conjugating a guanidinium-rich polymer (PG), a component that penetrates the biofilm matrix, onto ultrasound (US)-absorbing gold-doped titanate nanotubes (Au/TNTs). Under deep-penetrating US irradiation, the nanocomposite generates 1 O2 for sonodynamic therapy and catalyzes the decomposition of endogenous H2 O2 into toxic •OH in the acidic infection microenvironment for catalytic therapy, leading to bacterial cell death. Its robust antibacterial effectiveness is attributable to its bacteria-capturing ability, the biofilm penetrability of positively charged guanidinium, and the subsequent synergistic effect of sonodynamic-catalytic action of Au/TNT. Such a remotely controlled approach potentiates the polarization of macrophages to M2-type while suppressing the M1-type, leading to topical inflammation resolution and enhanced osteoblast proliferation and differentiation to inhibit bone loss. Therefore, this study provides a generic nanotherapeutic approach for efficient sonodynamic-catalytic therapy with respect to osteomyelitis.
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Affiliation(s)
- Yijie Cheng
- Key Laboratory of Functional Polymer Materials of Ministry of Education, Institute of Polymer Chemistry, College of Chemistry, Nankai University, Tianjin, 300071, P. R. China
| | - Yufei Zhang
- Key Laboratory of Functional Polymer Materials of Ministry of Education, Institute of Polymer Chemistry, College of Chemistry, Nankai University, Tianjin, 300071, P. R. China
| | - Zhe Zhao
- Department of Surgery of Traditional Chinese Medicine, Tianjin Hospital, Tianjin, 300211, P. R. China
| | - Gang Li
- No. 2 Department Radiology, Tianjin Hospital, Tianjin, 300211, P. R. China
| | - Jie Li
- Key Laboratory of Functional Polymer Materials of Ministry of Education, Institute of Polymer Chemistry, College of Chemistry, Nankai University, Tianjin, 300071, P. R. China
| | - Anran Li
- Key Laboratory of Functional Polymer Materials of Ministry of Education, Institute of Polymer Chemistry, College of Chemistry, Nankai University, Tianjin, 300071, P. R. China
| | - Yun Xue
- Key Laboratory of Functional Polymer Materials of Ministry of Education, Institute of Polymer Chemistry, College of Chemistry, Nankai University, Tianjin, 300071, P. R. China
| | - Baolin Zhu
- College of Chemistry, National Demonstration Center for Experimental Chemistry Education (Nankai University), The Key Laboratory of Advanced Energy Materials Chemistry (Ministry of Education) and Tianjin Key Lab of Metal and Molecule-based Material Chemistry, Nankai University, Tianjin, 300071, P. R. China
| | - Zhongming Wu
- Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, P. R. China
| | - Xinge Zhang
- Key Laboratory of Functional Polymer Materials of Ministry of Education, Institute of Polymer Chemistry, College of Chemistry, Nankai University, Tianjin, 300071, P. R. China
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169
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An analysis of 90-day emergency department visits after peripherally inserted central catheter (PICC) placement for prosthetic joint infection. Infect Control Hosp Epidemiol 2022; 43:1853-1858. [PMID: 35249571 DOI: 10.1017/ice.2022.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Research on complications with peripherally inserted central catheter (PICC) lines that are placed for the treatment of prosthetic joint infection (PJI) after total hip arthroplasty (THA) and total knee arthroplasty (TKA) is scarce. We investigated the timing, frequency, and risk factors for PICC complications during treatment of PJI after THA and TKA. METHODS We retrospectively queried an institutional database for THA and TKA patients from January 2015 through December 2020 that developed a PJI and required PICC placement at an academic, tertiary-care referral center. RESULTS The study included 889 patients (48.3% female) with a mean age of 64.6 years (range, 18.7-95.2) who underwent 435 THAs and 454 TKAs that were revised for PJI. The cohort had 275 90-day ED visits (30.9%), and 51 (18.5%) were PICC related. The average time from discharge to PICC ED visit was 26.2 days (range, 0.3-89.4). The most common reasons for a 90-day ED visit were issues related to the joint replacement or wound site (musculoskeletal or MSK; n = 116, 42.2%) and PICC complaints (n = 51, 18.5%). A multivariable logistic regression demonstrated that non-White race (odds ratio [OR], 2.24; 95% confidence interval [CI], 1.24-4.04; P = .007) and younger age (OR, 0.98; 95% CI, 0.95-1.00; P = .035) were associated with PICC-related ED visits. Malposition/readjustment (41.2%) and occlusion (35.3%) were the most common PICC complications leading to ED presentation. CONCLUSIONS PICC complications are common after PJI treatment, accounting for nearly 20% of 90-day ED visits.
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170
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Cortés-Penfield NW, Hewlett AL, Kalil AC. Adjunctive Rifampin Following Debridement and Implant Retention for Staphylococcal Prosthetic Joint Infection: Is it Effective if not Combined With a Fluoroquinolone? Open Forum Infect Dis 2022; 9:ofac582. [PMID: 36504699 PMCID: PMC9728514 DOI: 10.1093/ofid/ofac582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 10/28/2022] [Indexed: 11/07/2022] Open
Abstract
Whether rifampin benefits retained staphylococcal prosthetic joint infection is unsettled. In a meta-analysis of 8 studies, we found greater clinical cure with fluoroquinolone-rifampin vs all other regimens (odds ratio [OR], 2.68; 95% CI, 1.43-5.02), but no greater cure with other rifampin combinations vs regimens without rifampin (OR, 1.22; 95% CI, 0.79-1.88).
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Affiliation(s)
| | - Angela L Hewlett
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Andre C Kalil
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
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171
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Kreutzträger M, Lübstorf T, Ekkernkamp A, Blex C, Schwab JM, Kopp MA, Auhuber T, Wüstner G, Liebscher T. Spinal infection with intraspinal abscess or empyema and acute myelopathy: comparative analysis of diagnostics, therapy, complications and outcome in primary care. Eur J Trauma Emerg Surg 2022; 48:4745-4754. [PMID: 35657387 PMCID: PMC9712376 DOI: 10.1007/s00068-022-02001-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 05/06/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION This study on pyogenic spinal infections with intraspinal epidural involvement (PSI +) compared the outcome of patients with spinal cord injury (SCI) to those without (noSCI) taking diagnostic algorithm, therapy, and complications into account. METHODS Patients were enrolled in an ambispective study (2012-2017). Diagnostic and therapeutic algorithms, complications, and neurological outcome were analyzed descriptively. Survival was analyzed applying Kaplan-Meier method and Cox regression. RESULTS In total, 134 patients with a median (IQR) age of 72 (61-79) years were analyzed. Baseline characteristics were similar between the SCI (n = 55) and noSCI (n = 79). A higher percentage of endocarditis (9% vs. 0%; p = 0.03) was detected in the noSCI group. The majority (81%) received combinatorial therapy including spinal surgery and antibiotic treatment. The surgery complication rate was 16%. At discharge, improvement in neurologic function was present in 27% of the SCI patients. Length of stay, duration of ventilation and the burden of disease-associated complications were significantly higher in the SCI group (e.g., urinary tract infection, pressure ulcers). Lethality risk factors were age (HR 1.09, 95% CI 1.02-1.16, p = 0.014), and empyema/abscess extension (≥ 3 infected spinal segments, HR 4.72, 95% CI 1.57-14.20, p = 0.006), dominating over additional effects of Charlson comorbidity index, SCI, and type of treatment. The overall lethality rate was 11%. CONCLUSION PSI + are associated with higher in-hospital mortality, particularly when multiple spinal segments are involved. However, survival is similar with (SCI) or without myelopathy (noSCI). If SCI develops, the rate of disease complications is higher and early specialized SCI care might be substantial to reduce complication rates.
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Affiliation(s)
- Martin Kreutzträger
- Treatment Centre for Spinal Cord Injuries, BG Hospital Unfallkrankenhaus Berlin, Trauma Hospital Berlin, Warener Straße 7, 12683, Berlin, Germany.
- Department of Neurology and Experimental Neurology, Spinal Cord Injury Research, Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Tom Lübstorf
- Department of Neurology and Experimental Neurology, Spinal Cord Injury Research, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Axel Ekkernkamp
- Trauma Surgery and Orthopedics Clinic, BG Hospital Unfallkrankenhaus, Berlin, Germany
| | - Christian Blex
- Department of Neurology and Experimental Neurology, Spinal Cord Injury Research, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jan M Schwab
- Department of Neurology and Experimental Neurology, Spinal Cord Injury Research, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Spinal Cord Injury Division, Department of Neurology, Belford Center for Spinal Cord Injury, The Ohio State University, Wexner Medical Center, Columbus, OH, 43210, USA
- Department of Neuroscience, The Neurological Institute, The Ohio State University, Wexner Medical Center, Columbus, OH, 43210, USA
- Department of Physical Medicine and Rehabilitation, The Neurological Institute, The Ohio State University, Wexner Medical Center, Columbus, OH, 43210, USA
| | - Marcel A Kopp
- Department of Neurology and Experimental Neurology, Spinal Cord Injury Research, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health, QUEST - Center for Transforming Biomedical Research, Berlin, Germany
| | - Thomas Auhuber
- Medical Management, Trauma Hospital Berlin, Berlin, Germany
- University of the German Statutory Accident Insurance (HGU), Bad Hersfeld, Germany
| | - Grit Wüstner
- BG Hospital Unfallkrankenhaus Berlin, Berlin, Germany
| | - Thomas Liebscher
- Treatment Centre for Spinal Cord Injuries, BG Hospital Unfallkrankenhaus Berlin, Trauma Hospital Berlin, Warener Straße 7, 12683, Berlin, Germany
- Department of Neurology and Experimental Neurology, Spinal Cord Injury Research, Charité - Universitätsmedizin Berlin, Berlin, Germany
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172
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Staphylococcus lugdunensis prosthetic joint infection: A multicentric cohort study. J Infect 2022; 85:652-659. [DOI: 10.1016/j.jinf.2022.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 09/28/2022] [Accepted: 10/15/2022] [Indexed: 11/30/2022]
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173
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Buijs MAS, van den Kieboom J, Sliepen J, Wever KLH, van Breugel JM, Hietbrink F, IJpma FFA, Govaert GAM. Outcome and risk factors for recurrence of early onset fracture-related infections treated with debridement, antibiotics and implant retention: Results of a large retrospective multicentre cohort study. Injury 2022; 53:3930-3937. [PMID: 36307267 DOI: 10.1016/j.injury.2022.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 10/01/2022] [Accepted: 10/15/2022] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Early Fracture-Related Infections (FRIs) are a common entity in hospitals treating trauma patients and are often treated with a Debridement, Antibiotics and Implant Retention (DAIR) procedure. Aims of this study were to 1) evaluate the recurrence rate after DAIR procedures for early onset FRI, 2) establish the number of surgical procedures to gain control of the initial infection and 3) identify independent predictors for recurrence in this cohort. METHODS A retrospective multicentre cohort study was conducted in two level 1 trauma centres. Consecutive patients who underwent a DAIR procedure between January 1st 2015 and July 1st 2020 for confirmed FRI with an onset of <6 weeks after the latest osseous operation were included. Recorded data included patient demographics, treatment characteristics and follow-up. Univariate and multivariate logistic regression analyses were performed to assess predictors for recurrent FRI. RESULTS A total of 141 patients with early FRI were included in this study with a median age of 54.0 years (interquartile range (IQR) 34.5-64.0). The recurrence rate of FRI was 13% (n = 19) at one year follow-up and 18% (n = 25) at 23.1 months (IQR 15.3-36.4) follow-up. Infection control was achieved in 94% (n = 127/135) of cases. In total, 73 patients (52%) underwent at least two surgical procedures to treat the ongoing initial episode of FRI, of whom 54 patients (74%) required two to three procedures and 17 patients (23%) four to five procedures. Predictors for recurrent FRI were use of an intramedullary nail during index operation (odds ratio (OR) 4.0 (95% confidence interval (CI) 1.1-13.8)), need for additional surgical procedures to treat ongoing infection during the treatment period following the first presentation of early FRI (OR 1.9 (95% CI 1.1-3.5)) and a decreased Injury Severity Score (ISS) (inverted OR 1.1 (95% CI 1.0-1.1)). CONCLUSION The recurrence rate after treatment of early onset FRI in patients treated with a DAIR procedure was 18% at 23.1 months follow-up. At least two surgical procedures to gain control of the initial infection were needed in 52% of patients. Independent predictors for recurrent FRI were the use of an intramedullary nail during index operation, need for additional surgical procedures and a decreased ISS.
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Affiliation(s)
- M A S Buijs
- Department of Trauma Surgery, University Medical Centre Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - J van den Kieboom
- Department of Trauma Surgery, University Medical Centre Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - J Sliepen
- Department of Trauma Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - K L H Wever
- Department of Trauma Surgery, University Medical Centre Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - J M van Breugel
- Department of Trauma Surgery, University Medical Centre Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - F Hietbrink
- Department of Trauma Surgery, University Medical Centre Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - F F A IJpma
- Department of Trauma Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - G A M Govaert
- Department of Trauma Surgery, University Medical Centre Utrecht, University of Utrecht, Utrecht, The Netherlands.
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174
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Tong SYC, Mora J, Bowen AC, Cheng MP, Daneman N, Goodman AL, Heriot GS, Lee TC, Lewis RJ, Lye DC, Mahar RK, Marsh J, McGlothlin A, McQuilten Z, Morpeth SC, Paterson DL, Price DJ, Roberts JA, Robinson JO, van Hal SJ, Walls G, Webb SA, Whiteway L, Yahav D, Davis JS. The Staphylococcus aureus Network Adaptive Platform Trial Protocol: New Tools for an Old Foe. Clin Infect Dis 2022; 75:2027-2034. [PMID: 35717634 PMCID: PMC9710697 DOI: 10.1093/cid/ciac476] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Indexed: 01/17/2023] Open
Abstract
Staphylococcus aureus bloodstream (SAB) infection is a common and severe infectious disease, with a 90-day mortality of 15%-30%. Despite this, <3000 people have been randomized into clinical trials of treatments for SAB infection. The limited evidence base partly results from clinical trials for SAB infections being difficult to complete at scale using traditional clinical trial methods. Here we provide the rationale and framework for an adaptive platform trial applied to SAB infections. We detail the design features of the Staphylococcus aureus Network Adaptive Platform (SNAP) trial that will enable multiple questions to be answered as efficiently as possible. The SNAP trial commenced enrolling patients across multiple countries in 2022 with an estimated target sample size of 7000 participants. This approach may serve as an exemplar to increase efficiency of clinical trials for other infectious disease syndromes.
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Affiliation(s)
- Steven Y C Tong
- Department of Infectious Diseases University of Melbourne, Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Jocelyn Mora
- Department of Infectious Diseases University of Melbourne, Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Asha C Bowen
- Department of Infectious Diseases, Perth Children's Hospital, Perth, Australia.,Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Australia
| | - Matthew P Cheng
- Divisions of Infectious Diseases and Medical Microbiology, McGill University Health Centre, Montreal, Canada
| | - Nick Daneman
- Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Anna L Goodman
- Medical Research Council Clinical Trials Unit, University College London, London, United Kingdom.,Department of Infection, St Thomas Hospital, Guy's and St Thomas NHS Foundation Trust, London, United Kingdom
| | - George S Heriot
- Department of Infectious Diseases University of Melbourne, Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Todd C Lee
- Clinical Practice Assessment Unit and Division of Infectious Diseases, McGill University, Montreal, Canada
| | - Roger J Lewis
- Berry Consultants, LLC, Austin, Texas, USA.,Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California, USA.,Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - David C Lye
- National Centre for Infectious Diseases, Singapore.,Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore.,Yong Loo Lin School of Medicine, Singapore.,Lee Kong Chian School of Medicine, Singapore
| | - Robert K Mahar
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Australia.,Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, Australia
| | - Julie Marsh
- Telethon Kids Institute, Perth Children's Hospital, Perth, Australia
| | | | - Zoe McQuilten
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.,Department of Haematology, Monash Health, Melbourne, Australia
| | - Susan C Morpeth
- Department of Infectious Diseases, Middlemore Hospital, Auckland, New Zealand
| | - David L Paterson
- University of Queensland Centre for Clinical Research, Royal Brisbane and Women's Hospital Campus, Brisbane, Australia
| | - David J Price
- Department of Infectious Diseases University of Melbourne, Peter Doherty Institute for Infection and Immunity, Melbourne, Australia.,Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, University of Queensland, Brisbane, Australia.,Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - J Owen Robinson
- Department of Infectious Diseases, Royal Perth Hospital, Perth, Australia.,Department of Infectious Diseases, Fiona Stanley Hospital, Murdoch, Australia.,PathWest Laboratory Medicine, Perth, Australia.,College of Science, Health, Engineering and Education, Murdoch University, Murdoch, Australia
| | - Sebastiaan J van Hal
- Department of Microbiology and Infectious Diseases Royal Prince Alfred Hospital, Sydney, Australia.,School of Medicine, University of Sydney, Sydney, Australia
| | - Genevieve Walls
- Department of Infectious Diseases, Middlemore Hospital, Auckland, New Zealand
| | - Steve A Webb
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Lyn Whiteway
- Freelance Health Consumer Advocate, Adealide, South Australia, Australia
| | - Dafna Yahav
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Joshua S Davis
- School of Medicine and Public Health and Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
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175
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Passerini M, Maamari J, Nayfeh T, Hassett LC, Tande AJ, Murad MH, Temesgen Z, Berbari EF. Early switch to oral antibiotic therapy for the treatment of patients with bacterial native vertebral osteomyelitis: a quaternary center experience, systematic review, and meta-analysis. J Bone Jt Infect 2022; 7:249-257. [DOI: 10.5194/jbji-7-249-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/26/2022] [Indexed: 11/24/2022] Open
Abstract
Abstract. Recent data suggest that oral therapy can be effective for bone infections.
We aim to assess the efficacy of an early switch to oral therapy (<2 weeks) compared to a non-early switch in bacterial native vertebral
osteomyelitis. We conducted a cohort study at Mayo Clinic, Rochester (MN),
between 2019–2021 combined with a systematic review, which queried multiple
databases. Data were analyzed using a random-effects model. The cohort study
included 139 patients: two received an early switch. Of 3708 citations, 13
studies were included in the final analysis. Meta-analysis demonstrated no
difference in treatment failure (odds ratio = 1.073, 95 % confidence
interval 0.370–3.116), but many studies presented high risk of bias. Current
evidence is insufficient to conclude the proportion of patients with failure
or relapse is different in the two groups. High-quality studies are
warranted before early switch can be routinely recommended.
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176
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Platts S, Payne BA, Price DA, Pareja-Cebrian L, Schwab U. Oral step-down for Staphylococcus aureus bacteraemia: An opportunity for antimicrobial stewardship? CLINICAL INFECTION IN PRACTICE 2022; 16:100202. [DOI: 10.1016/j.clinpr.2022.100202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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177
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Schechter MC, Sax PE, Cortés-Penfield N. What Is the Best Oral Therapy for Staph aureus Osteomyelitis? NEJM EVIDENCE 2022; 1:EVIDtt2200119. [PMID: 38319854 DOI: 10.1056/evidtt2200119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Best Oral Therapy for Staph aureus OsteomyelitisA 50-year-old patient with diabetes mellitus has a plantar ulcer at the base of the first metatarsal. Cortical erosions are noted; bone biopsy culture yields Staphylococcus aureus susceptible to methicillin, ciprofloxacin, clindamycin, doxycycline, trimethoprim/sulfamethoxazole, linezolid, and rifampin. The plan is for 4 weeks of antibiotic treatment. Which antibiotic should be prescribed?
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Affiliation(s)
- Marcos C Schechter
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta
- Grady Memorial Hospital, Atlanta
| | - Paul E Sax
- Division of Infectious Diseases, Brigham and Women's Hospital and Harvard Medical School, Boston
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178
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Kendal A, Loizou C, Down B, McNally M. Long-Term Follow-up of Complex Calcaneal Osteomyelitis Treated With Modified Gaenslen Approach. FOOT & ANKLE ORTHOPAEDICS 2022; 7:24730114221133391. [PMID: 36329689 PMCID: PMC9623373 DOI: 10.1177/24730114221133391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background The treatment of chronic calcaneal osteomyelitis is a challenging and increasing problem because of the high prevalence of diabetes mellitus and operative fixation of heel fractures. In 1931, Gaenslen reported treatment of hematogenous calcaneal osteomyelitis by surgical excision through a midline, sagittal plantar incision. We have refined this approach to allow successful healing and early mobilization in a modern series of complex patients with hematogenous, diabetic, and postsurgical osteomyelitis. Methods Twenty-eight patients (mean age 54.6 years, range 20-94) with Cierny-Mader stage IIIB chronic calcaneal osteomyelitis were treated with sagittal incision and calcaneal osteotomy, excision of infected bone, and wound closure. All patients received antibiotics for at least 6 weeks, and bone defects were filled with an antibiotic carrier in 20 patients. Patients were followed for a mean of 31 months (SD 25.4). Primary outcome measures were recurrence of calcaneal osteomyelitis and below-knee amputation. Secondary outcome measures included 30-day postoperative mortality and complications, duration of postoperative inpatient stay, footwear adaptions, mobility, and use of walking aids. Results All 28 patients had failed previous medical and surgical treatment. Eighteen patients (64%) had significant comorbidities. The commonest causes of infection were diabetes ± ulceration (11 patients), fracture-related infection (4 patients), pressure ulceration, hematogenous spread, and penetrating soft tissue trauma. The overall recurrence rate of calcaneal osteomyelitis was 18% (5 patients) over the follow-up period, of which 2 patients (7%) required a below-knee amputation. Eighteen patients (64%) had a foot that comfortably fitted into a normal shoe with a custom insole. A further 6 patients (21%) required a custom-made shoe, and only 3 patients required a custom-made boot. Conclusion Our results show that a repurposed Gaenslen calcanectomy is simple, safe, and effective in treating this difficult condition in a patient group with significant local and systemic comorbidities. Level of Evidence Level III, case series.
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Affiliation(s)
- Adrian Kendal
- Nuffield Orthopaedic Centre, Oxford,
UK,Botnar Research Centre, The Nuffield
Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford,
UK,Adrian Kendal, MA, BMBCh, DPhil, FRCS,
Botnar Research Centre, The Nuffield Department of Orthopaedics, Rheumatology
and Musculoskeletal Sciences, Windmill Road, Oxford, OX3 7LD, UK.
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179
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Moriarty TF, Metsemakers WJ, Morgenstern M, Hofstee MI, Vallejo Diaz A, Cassat JE, Wildemann B, Depypere M, Schwarz EM, Richards RG. Fracture-related infection. Nat Rev Dis Primers 2022; 8:67. [PMID: 36266296 DOI: 10.1038/s41572-022-00396-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/13/2022] [Indexed: 11/09/2022]
Abstract
Musculoskeletal trauma leading to broken and damaged bones and soft tissues can be a life-threating event. Modern orthopaedic trauma surgery, combined with innovation in medical devices, allows many severe injuries to be rapidly repaired and to eventually heal. Unfortunately, one of the persisting complications is fracture-related infection (FRI). In these cases, pathogenic bacteria enter the wound and divert the host responses from a bone-healing course to an inflammatory and antibacterial course that can prevent the bone from healing. FRI can lead to permanent disability, or long courses of therapy lasting from months to years. In the past 5 years, international consensus on a definition of these infections has focused greater attention on FRI, and new guidelines are available for prevention, diagnosis and treatment. Further improvements in understanding the role of perioperative antibiotic prophylaxis and the optimal treatment approach would be transformative for the field. Basic science and engineering innovations will be required to reduce infection rates, with interventions such as more efficient delivery of antibiotics, new antimicrobials, and optimizing host defences among the most likely to improve the care of patients with FRI.
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Affiliation(s)
- T Fintan Moriarty
- AO Research Institute Davos, Davos, Switzerland.,Center for Musculoskeletal Infections, Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Mario Morgenstern
- Center for Musculoskeletal Infections, Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | | | - Alejandro Vallejo Diaz
- Department of Orthopedics and Traumatology, Hospital Alma Mater de Antioquia, Medellín, Colombia.,Department of Orthopedics and Traumatology, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - James E Cassat
- Department of Paediatrics, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Biomedical Engineering, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Britt Wildemann
- Experimental Trauma Surgery, Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Melissa Depypere
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium.,Department of Microbiology, Immunology and Transplantation, Laboratory of Clinical Bacteriology and Mycology, KU Leuven, Leuven, Belgium
| | - Edward M Schwarz
- Center for Musculoskeletal Research, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - R Geoff Richards
- AO Research Institute Davos, Davos, Switzerland. .,School of Veterinary Science, Aberystwyth University, Aberystwyth, UK.
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180
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Stevenson N, Suttie S, Fernandes E, Rae N. Acute infections in people who inject drugs. BMJ 2022; 379:e072635. [PMID: 36207027 DOI: 10.1136/bmj-2022-072635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
| | - Stuart Suttie
- Department of Vascular Surgery, Ninewells Hospital, Dundee
| | - Eduardo Fernandes
- Department of Surgery, University of Illinois Health Science System, Chicago, Illinois, USA
| | - Nikolas Rae
- Infection Unit, Ninewells Hospital, Dundee DD1 9SY, UK
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181
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Moore N, Kohut M, Stoddard H, Burris D, Chessa F, Sikka MK, Solomon D, Kershaw CM, Eaton E, Hutchinson R, Fairfield KM, Stopka TJ, Friedmann P, Thakarar K. Health care professional perspectives on discharging hospitalized patients with injection drug use-associated infections. Ther Adv Infect Dis 2022; 9:20499361221126868. [PMID: 36225855 PMCID: PMC9549088 DOI: 10.1177/20499361221126868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 08/30/2022] [Indexed: 11/07/2022] Open
Abstract
Background: Patients with injection drug use (IDU)-associated infections traditionally
experience prolonged hospitalizations, which often result in negative
experiences and bad outcomes. Harm reduction approaches that value patient
autonomy and shared decision-making regarding outpatient treatment options
may improve outcomes. We sought to identify health care professionals (HCPs)
perspectives on the barriers to offering four different options to
hospitalized people who use drugs (PWUD): long-term hospitalization, oral
antibiotics, long-acting antibiotics at an infusion center, and outpatient
parenteral antibiotics. Methods: We recruited HCPs (n = 19) from a single tertiary care
center in Portland, Maine. We interviewed HCPs involved with discharge
decision-making and other HCPs involved in the specialized care of PWUD.
Semi-structured interviews elicited lead HCP values, preferences, and
concerns about presenting outpatient antimicrobial treatment options to
PWUD, while support HCPs provided contextual information. We used the
iterative categorization approach to code and thematically analyze
transcripts. Results: HCPs were willing to present outpatient treatment options for patients with
IDU-associated infections, yet several factors contributed to reluctance.
First, insufficient resources, such as transportation, may make these
options impractical. However, HCPs may be unaware of existing community
resources or viable treatment options. They also may believe the hospital
protects patients, and that discharging patients into the community exposes
them to structural harms. Some HCPs are concerned that patients with
substance use disorder will not make ‘good’ decisions regarding outpatient
antimicrobial options. Finally, there is uncertainty about how
responsibility for offering outpatient treatment is shared across changing
care teams. Conclusion: HCPs perceive many barriers to offering outpatient care for people with
IDU-associated infections, but with appropriate interventions to address
their concerns, may be open to considering more options. This study provides
important insights and contextual information that can help inform specific
harm reduction interventions aimed at improving care of people with
IDU-associated infections.
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Affiliation(s)
- Nichole Moore
- Tufts University School of Medicine, Boston,
MA, USA
| | - Michael Kohut
- Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA
| | - Henry Stoddard
- Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA
| | - Debra Burris
- Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA
| | - Frank Chessa
- Tufts University School of Medicine, Boston,
MA, USA
| | - Monica K. Sikka
- Division of Infectious Diseases, Department of
Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Daniel Solomon
- Division of Infectious Disease, Brigham and
Women’s Hospital, Boston, MA, USA
| | - Colleen M. Kershaw
- Section of Infectious Disease and International
Health, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA,Geisel School of Medicine at Dartmouth,
Hanover, NH, USA
| | - Ellen Eaton
- Division of Infectious Disease, The University
of Alabama at Birmingham, Birmingham, AL, USA
| | - Rebecca Hutchinson
- Tufts University School of Medicine, Boston,
MA, USA,Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA,Maine Medical Center, Portland, ME, USA
| | - Kathleen M. Fairfield
- Tufts University School of Medicine, Boston,
MA, USA,Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA,Maine Medical Center, Portland, ME, USA
| | - Thomas J. Stopka
- Department of Public Health & Community
Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Peter Friedmann
- Office of Research, UMass Chan Medical
School-Baystate, Springfield, MA, USA,Frank Chessa is also affiliated to MaineHealth
Institute for Research, Portland, ME, USA; Maine Medical Center, Portland,
ME, USA
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182
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Bouji N, Wen S, Dietz M. Intravenous antibiotic duration in the treatment of prosthetic joint infection: systematic review and meta-analysis. J Bone Jt Infect 2022; 7:191-202. [PMID: 36267262 PMCID: PMC9562697 DOI: 10.5194/jbji-7-191-2022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 08/20/2022] [Indexed: 08/22/2023] Open
Abstract
Introduction: Long antibiotic courses, including intravenous (IV) and oral administrations, are utilized in prosthetic joint infection (PJI) treatment. This meta-analysis examines the non-inferiority of short courses ( < 4 weeks) of IV antibiotics compared to long courses in treating PJI. Critical review of IV treatment is necessary due to the clinical, physical, and financial burden associated with it and its continued prolonged use in the US without much evidence to support the practice. Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), databases were searched using predefined medical subject headings (MeSH). Results: The nine included studies reported 521 total hip arthroplasties (THAs) and 530 total knee arthroplasties (TKAs). There was no significant difference in the overall success rate in short- vs. long-duration IV antibiotics for PJI treatment: odds ratio (OR) of 1.65, 95 % confidence interval (CI) of 0.78-3.46, and p = 0 .18. However, due to the moderate to high heterogeneity (I 2 = 68 %, p < 0.01) amongst studies, an adjusted success rate was calculated after the exclusion of two studies. This showed a statistically significant difference between both groups (OR of 2.45, 95 % CI of 1.21-4.96, p < 0.001) favoring a short course of antibiotics and reflecting a more homogenous population (I 2 = 51 %, p = 0 .06). Conclusion: This study highlights the limited data available for evaluating IV antibiotic duration in the setting of PJI. We found that a shorter duration of IV antibiotics was non-inferior to a longer duration, with an improved OR of 2.45 for treatment success, likely shortening inpatient stay as well as lessening side effects and antimicrobial resistance with a lower cost to patients and overall healthcare.
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Affiliation(s)
- Nour Bouji
- Department of Orthopaedics, School of
Medicine, West Virginia University, Morgantown, WV 26506, USA
| | - Sijin Wen
- Department of Epidemiology and BioStatistics, School of Public Health, West Virginia University, Morgantown, WV 26506, USA
| | - Matthew J. Dietz
- Department of Orthopaedics, School of
Medicine, West Virginia University, Morgantown, WV 26506, USA
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183
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McNally MA, Ferguson JY, Scarborough M, Ramsden A, Stubbs DA, Atkins BL. Mid- to long-term results of single-stage surgery for patients with chronic osteomyelitis using a bioabsorbable gentamicin-loaded ceramic carrier. Bone Joint J 2022; 104-B:1095-1100. [PMID: 36047024 PMCID: PMC9948464 DOI: 10.1302/0301-620x.104b9.bjj-2022-0396.r1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Excision of chronic osteomyelitic bone creates a dead space which must be managed to avoid early recurrence of infection. Systemic antibiotics cannot penetrate this space in high concentrations, so local treatment has become an attractive adjunct to surgery. The aim of this study was to present the mid- to long-term results of local treatment with gentamicin in a bioabsorbable ceramic carrier. METHODS A prospective series of 100 patients with Cierny-Mader Types III and IV chronic ostemyelitis, affecting 105 bones, were treated with a single-stage procedure including debridement, deep tissue sampling, local and systemic antibiotics, stabilization, and immediate skin closure. Chronic osteomyelitis was confirmed using strict diagnostic criteria. The mean follow-up was 6.05 years (4.2 to 8.4). RESULTS At final follow-up, six patients (six bones) had recurrent infection; thus 94% were infection-free. Three infections recurred in the first year, two in the second year, and one 4.5 years postoperatively. Recurrence was not significantly related to the physiological class of the patient (1/20 Class A (5%) vs 5/80 Class B (6.25%); p = 0.833), nor was it significantly related to the aetiology of the infection, the organisms which were cultured or the presence of nonunion before surgery (1/10 with nonunion (10%) vs 5/90 without nonunion (5.6%); p = 0.570). Organisms with intermediate or high-grade resistance to gentamicin were significantly more likely in polymicrobial infections (9/21; 42.8%) compared with monobacterial osteomyelitis (7/79 (8.9%); p < 0.001). However, recurrence was not significantly more frequent when a resistant organism was present (1/16 for resistant cases (6.25%) vs 5/84 in those with a microbiologically sensitive infection (5.95%); p = 0.958). CONCLUSION We found that a single-stage protocol, including the use of a high-delivery local antibiotic ceramic carrier, was effective over a period of several years. The method can be used in a wide range of patients, including those with significant comorbidities and an infected nonunion.Cite this article: Bone Joint J 2022;104-B(9):1095-1100.
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Affiliation(s)
- Martin A. McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK,Correspondence should be sent to Professor Martin A. McNally. E-mail:
| | - Jamie Y. Ferguson
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Matthew Scarborough
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Alex Ramsden
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - David A. Stubbs
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Bridget L. Atkins
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
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184
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Alcobendas Rueda RM, Núñez E, Martín L, Hernández MB, Saavedra-Lozano J, Udaondo C, Murias S, Remesal A, Calvo C. Oral Versus Intravenous Antibiotics for Pediatric Osteoarticular Infection: When and to Whom? Pediatr Infect Dis J 2022; 41:e351-e357. [PMID: 35763692 DOI: 10.1097/inf.0000000000003619] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Osteoarticular infections (OAIs) are typically treated initially with intravenous antibiotics. The objective of this study was to evaluate whether an exclusive oral treatment in selected children may be appropriate. METHODS The Spanish Network of Osteoarticular Infections is a nationwide multicenter registry comprising 37 hospitals in Spain. The registry prospectively includes clinical characteristics and outcome of children with OAI. One of the hospitals from RioPed offers oral treatment to children meeting certain criteria. Patients were classified into 2 groups. Group 1: management with initial intravenous antibiotic therapy. Group 2: patients exclusively treated with oral antibiotics. A comparison between the 2 groups was performed. RESULTS We compared 893 children who initially received intravenous antibiotics (group 1) with 64 children who received exclusively oral therapy (group 2). Patients from group 2 were younger (33.9 vs. 20.3 months; P = 0.001), had a lower percentage of Staphylococcus aureus (23.3% vs. 3.1%; P < 0.001), a higher proportion of Kingella kingae (12.1% vs. 28.1%; P = 0.001), higher erythrocyte sedimentation rate/C-reactive protein (CRP) ratio (1.4 interquartile range 0.6-3.6 vs. 3.3 interquartile range 1.7-5.7; P < 0.001) and showed lower rate of fever (63% vs. 48.8%; P = 0.024) than in group 1. Complications were not found in group 2. CONCLUSIONS An exclusively oral administration could be a safe option in selected patients with OAI. Low-risk criteria are proposed: good general condition, no underlying disease, 6 months to 3 years old, appropriate oral tolerance, C-reactive protein <80 mg/L, erythrocyte sedimentation rate/C-reactive protein ratio ≥0.67, no skin injury, no recent surgery, no cervical spondylodiscitis and no local complications at onset.
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Affiliation(s)
| | - Esmeralda Núñez
- Pediatrics Department, Hospital Materno-Infantil, Málaga, Spain
| | - Laura Martín
- Pediatrics Department, Hospital Materno-Infantil, Málaga, Spain
| | | | - Jesús Saavedra-Lozano
- Pediatric Infectious Diseases Unit, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid
| | - Clara Udaondo
- From the, Pediatric Rheumatology Unit, Hospital Universitario La Paz
| | - Sara Murias
- From the, Pediatric Rheumatology Unit, Hospital Universitario La Paz
| | - Agustin Remesal
- From the, Pediatric Rheumatology Unit, Hospital Universitario La Paz
| | - Cristina Calvo
- Pediatric Infectious Diseases Department, Hospital Universitario La Paz, Madrid, Spain
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185
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Sanchez MJ, Patel K, Lindsay EA, Tareen NG, Jo C, Copley LA, Sue PK. Early Transition to Oral Antimicrobial Therapy Among Children With Staphylococcus aureus Bacteremia and Acute Hematogenous Osteomyelitis. Pediatr Infect Dis J 2022; 41:690-695. [PMID: 35703303 DOI: 10.1097/inf.0000000000003594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Staphylococcus aureus bacteremia (SAB) is a frequent complication of acute hematogenous osteomyelitis (AHO) in children, but data on the optimal duration of parenteral antibiotics prior to transition to oral antibiotics remains sparse. We examined clinical outcomes associated with early transition to oral antimicrobial therapy among children admitted to our institution with AHO and SAB, and evaluated the utility of a severity of illness score (SIS) to guide treatment decisions in this setting. METHODS Children with AHO and SAB admitted to our institution between January 1, 2009, and December 31, 2018, were retrospectively reviewed and stratified according to a previously validated SIS into mild (0-3), moderate (4-7) and severe (8-10) cohorts. Groups were assessed for differences in treatment (eg, parenteral and oral antibiotic durations, surgeries) and clinical response (eg, bacteremia duration, acute kidney injury, length of stay and treatment failure). RESULTS Among 246 children identified with AHO and SAB, median parenteral antibiotic duration differed significantly between mild (n = 80), moderate (n = 98) and severe (n = 68) cohorts (3.6 vs. 6.5 vs. 14.3 days; P ≤ 0.001). SIS cohorts also differed with regard to number of surgeries (0.4 vs. 1.0 vs. 2.1; P ≤ 0.001), duration of bacteremia (1.0 vs. 2.0 vs. 4.0 days; P ≤ 0.001), acute kidney injury (0.0% vs. 3.0% vs. 20.5%; P ≤ 0.001), hospital length of stay (4.8 vs. 7.4 vs. 16.4 days; P ≤ 0.001) and total duration of antibiotics (34.5 vs. 44.7 vs. 60.7 days; P ≤ 0.001). Early transition to oral antimicrobial therapy among mild or moderate SIS cohorts was not associated with treatment failure despite SAB. CONCLUSIONS SAB is associated with a wide range of illness among children with AHO, and classification of severity may be useful for guiding treatment decisions. Early transition to oral antimicrobial therapy appears safe in children with mild or moderate AHO despite the presence of SAB.
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Affiliation(s)
- Maria J Sanchez
- From the Department of Pediatrics, Children's Health System of Texas
| | - Karisma Patel
- Department of Pharmacy, University of Texas Southwestern Medical Center, Children's Health System of Texas, Dallas, Texas
| | - Eduardo A Lindsay
- Department of Family Medicine, Mayagüez Medical Center, Mayagüez, Puerto Rico
| | - Naureen G Tareen
- From the Department of Pediatrics, Children's Health System of Texas
| | - Chanhee Jo
- Research Department, Texas Scottish Rite Hospital for Children
| | - Lawson A Copley
- Department of Orthopaedic Surgery and Pediatrics, University of Texas Southwestern Medical Center, Children's Health System of Texas, Texas Scottish Rite Hospital for Children, Dallas, Texas
| | - Paul K Sue
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Texas Southwestern Medical Center, Dallas
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186
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Mareau J, Alexander B, Egge J, Heintz B, Suzuki H, Livorsi DJ. Eligibility for and Use of Oral Antimicrobial Therapy Among Veterans With Osteoarticular Infections: A Retrospective Study Across 8 Medical Centers. Open Forum Infect Dis 2022; 9:ofac450. [PMID: 36119960 PMCID: PMC9472666 DOI: 10.1093/ofid/ofac450] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/26/2022] [Indexed: 08/31/2023] Open
Abstract
We retrospectively evaluated antimicrobial therapy in 145 randomly selected patients with osteoarticular infections across 8 hospitals. One hundred nine (75%) were eligible for oral antimicrobial therapy, but only 18 received it: 5 of 39 (13%) in 2018 versus 13 of 70 (19%) in 2019-2020 (P = .44). Oral antimicrobials may be underutilized for osteoarticular infections in routine practice.
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Affiliation(s)
- Jacquelyn Mareau
- Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Bruce Alexander
- Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Jason Egge
- Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Brett Heintz
- Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Hiroyuki Suzuki
- Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
- Division of Infectious Diseases, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Daniel J Livorsi
- Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
- Division of Infectious Diseases, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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187
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Bureau A, Bourget-Murray J, Azad MA, Abdelbary H, Grammatopoulos G, Garceau SP. Management of Periprosthetic Joint Infections After Hemiarthroplasty of the Hip: A Critical Analysis Review. JBJS Rev 2022; 10:01874474-202209000-00006. [PMID: 36155552 DOI: 10.2106/jbjs.rvw.22.00020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
➢ Periprosthetic joint infection (PJI) following hip hemiarthroplasty (HA) is a devastating complication, incurring immense health-care costs associated with its treatment and placing considerable burden on patients and their families. These patients often require multiple surgical procedures, extended hospitalization, and prolonged antimicrobial therapy. ➢ Notable risk factors include older age, higher American Society of Anesthesiologists (ASA) score, inadequate antibiotic prophylaxis, non-antibiotic-loaded cementation of the femoral implant, longer duration of the surgical procedure, and postoperative drainage and hematoma. ➢ Although the most frequent infecting organisms are gram-positive cocci such as Staphylococcus aureus, there is a higher proportion of patients with gram-negative and polymicrobial infections after hip HA compared with patients who underwent total hip arthroplasty. ➢ Several surgical strategies exist. Regardless of the preferred surgical treatment, successful management of these infections requires a comprehensive surgical debridement focused on eradicating the biofilm followed by appropriate antibiotic therapy. ➢ A multidisciplinary approach led by surgeons familiar with PJI treatment and infectious disease specialists is recommended for all cases of PJI after hip HA to increase the likelihood of treatment success.
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Affiliation(s)
- Antoine Bureau
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Marisa A Azad
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Hesham Abdelbary
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Simon P Garceau
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
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188
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Successful Integration of Clinical Pharmacists in an OPAT Program: A Real-Life Multidisciplinary Circuit. Antibiotics (Basel) 2022; 11:antibiotics11081124. [PMID: 36009993 PMCID: PMC9404975 DOI: 10.3390/antibiotics11081124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/08/2022] [Accepted: 08/16/2022] [Indexed: 11/16/2022] Open
Abstract
Outpatient parenteral antimicrobial therapy (OPAT) programs encompass a range of healthcare processes aiming to treat infections at home, with the preferential use of the intravenous route. Although several barriers arise during the implementation of OPAT circuits, recent cumulative data have supported the effectiveness of these programs, demonstrating their application in a safe and cost-effective manner. Given that OPAT is evolving towards treating patients with higher complexity, a multidisciplinary team including physicians, pharmacists, and nursing staff should lead the program. The professionals involved require previous experience in infectious diseases treatment as well as in outpatient healthcare and self-administration. As we describe here, clinical pharmacists exert a key role in OPAT multidisciplinary teams. Their intervention is essential to optimize antimicrobial prescriptions through their participation in stewardship programs as well as to closely follow patients from a pharmacotherapeutic perspective. Moreover, pharmacists provide specialized counseling on antimicrobial treatment technical compounding. In fact, OPAT elaboration in sterile environments and pharmacy department clean rooms increases OPAT stability and safety, enhancing the quality of the program. In summary, building multidisciplinary teams with the involvement of clinical pharmacists improves the management of home-treated infections, promoting a safe self-administration and increasing OPAT patients’ quality of life.
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189
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Gálvez-Sirvent E, Ibarzábal-Gil A, Rodríguez-Merchán EC. Complications of the surgical treatment of fractures of the tibial plateau: prevalence, causes, and management. EFORT Open Rev 2022; 7:554-568. [PMID: 35924649 PMCID: PMC9458943 DOI: 10.1530/eor-22-0004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Open reduction and internal fixation is the gold standard treatment for tibial plateau fractures. However, the procedure is not free of complications such as knee stiffness, acute infection, chronic infection (osteomyelitis), malunion, non-union, and post-traumatic osteoarthritis. The treatment options for knee stiffness are mobilisation under anaesthesia (MUA) when the duration is less than 3 months, arthroscopic release when the duration is between 3 and 6 months, and open release for refractory cases or cases lasting more than 6 months. Early arthroscopic release can be associated with MUA. Regarding treatment of acute infection, if the fracture has healed, the hardware can be removed, and lavage and debridement can be performed along with antibiotic therapy. If the fracture has not healed, the hardware is retained, and lavage, debridement, and antibiotic therapy are performed (sometimes more than once until the fracture heals). Fracture stability is important not only for healing but also for resolving the infection. In cases of osteomyelitis, treatment should be performed in stages: aggressive debridement of devitalised tissue and bone, antibiotic spacing and temporary external fixation until the infection is resolved (first stage), followed by definitive surgery with grafting or soft tissue coverage depending on the bone defect (second stage). Intra-articular or extra-articular osteotomy is a good option to correct malunion in young, active patients without significant joint damage. When malunion is associated with extensive joint involvement or the initial cartilage damage has resulted in knee osteoarthritis, the surgical option is total knee arthroplasty.
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Affiliation(s)
- Elena Gálvez-Sirvent
- Department of Orthopaedic Surgery, "Infanta Elena" University Hospital, Valdemoro, Madrid, Spain.,Faculty of Medicine, Universidad Francisco de Vitoria, Madrid, Spain
| | - Aitor Ibarzábal-Gil
- Department of Orthopaedic Surgery, "La Paz" University Hospital, Madrid, Spain
| | - E Carlos Rodríguez-Merchán
- Department of Orthopaedic Surgery, "La Paz" University Hospital, Madrid, Spain.,Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research - IdiPAZ (La Paz University Hospital - Autonomous University of Madrid), Madrid, Spain
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190
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Howard T, Reichert I, Giddie J, Ahluwalia R. Treatment of Infected Nonunions With Bone Defects Using Autologous Bone Graft and Absorbable Antibiotic-Loaded Calcium Sulfate-Hydroxyapatite Paste. Foot Ankle Int 2022; 43:1007-1021. [PMID: 35856290 DOI: 10.1177/10711007221094013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Revision surgery in the presence of infection carries high risks. We describe our results using a new technique to treat these challenging problems. We treated infected nonunions with cavitary voids with adjuvant antibiotic loaded calcium sulfate-hydroxyapatite paste composite and autologous bone graft (ABG) layer technique coupled with stable fixation. METHODS Thirty consecutive patients who underwent revision foot and ankle surgery for an infected nonunion were prospectively studied. Following multidisciplinary team workup, surgical debridement and biopsies were undertaken. Bone voids were measured and classified according to containment and size. ABG was mixed and layered with an adjuvant antibiotic-loaded calcium sulfate-hydroxyapatite paste followed by surgical reconstruction including arthrodesis and fixation. Empirical and pathogen-specific antibiotics were instituted until intraoperative sample-specific antibiotics were identified and used. Patients were prospectively followed up for a minimum of 1 year. RESULTS The male-female ratio was 16:14, mean age was 51.3 years, and 23.3% smoked at definitive surgery. Void volume was <1 cm3 (n=9), 1-2 cm3 (n = 13), and >2 cm3 (n=8). No patients either were lost to follow-up or had a further infective episode at a mean of 38.3 months; 86.7% united with fusion on imaging. Four patients had radiographic evidence of nonunion; 3 were asymptomatic and 1 required revision surgery (void >2 cm3). Independent ambulation was achieved at an average of 12 weeks, at 1 year mean American Orthopaedic Foot & Ankle Society score was 77.7 (SD 9.59), and the Manchester-Oxford Foot Questionnaire reached an effect size >0.5 in all domains at 1 year following surgery. The union rate was independent of smoking status and vitamin D deficiency (P = .94). CONCLUSION Layered autologous bone grafting with adjuvant antibiotic-loaded calcium sulfate-hydroxyapatite paste has been shown to be effective and safe in revision arthrodesis, with low comorbidities in void gaps without infection recurrence.
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Affiliation(s)
- Theodore Howard
- Department of Orthopaedics, King's College Hospital, Brixton, London, United Kingdom.,King's Diabetic Foot Unit, King's College Hospital, London, United Kingdom
| | - Ines Reichert
- Department of Orthopaedics, King's College Hospital, Brixton, London, United Kingdom.,King's Diabetic Foot Unit, King's College Hospital, London, United Kingdom
| | - Jasdeep Giddie
- Department of Orthopaedics, King's College Hospital, Brixton, London, United Kingdom.,King's Diabetic Foot Unit, King's College Hospital, London, United Kingdom
| | - Raju Ahluwalia
- Department of Orthopaedics, King's College Hospital, Brixton, London, United Kingdom.,King's Diabetic Foot Unit, King's College Hospital, London, United Kingdom
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191
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Moderate to Severe Soft Tissue Diabetic Foot Infections: A Randomized, Controlled, Pilot Trial of Post-debridement Antibiotic Treatment for 10 versus 20 days. Ann Surg 2022; 276:233-238. [PMID: 35623048 PMCID: PMC9259031 DOI: 10.1097/sla.0000000000005205] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The optimal duration of antibiotic therapy for soft-tissue infections of the diabetic foot remains unknown. OBJECTIVE We determine if antibiotic therapy after debridement for a short (10 days), compared with a long (20 days), duration for soft-tissue infections of the diabetic foot results in similar rates of clinical remission and adverse events (AE). SUMMARY OF BACKGROUND DATA The optimal duration of systemic antibiotic therapy, after successful debridement, for soft tissue infections of diabetic patients is unknown. Because of the high recurrence risk, overuse is commonplace. METHODS This was a randomized, controlled, non-inferiority pilot trial of cases of diabetic foot infection (excluding osteomyelitis) with the primary outcome of "clinical remission at 2-months follow-up". RESULTS Among 66 enrolled episodes (17% females; median age 71 years), we randomized 35 to the 10-day arm and 31 to the 20-day arm. The median duration of the parenteral antibiotic therapy was 1 day, with the remainder given orally. In the intention-to-treat population, we achieved clinical remission in 27 (77%) patients in the 10-day arm compared to 22 (71%) in the 20-days arm ( P = 0.57). There were a similar proportion in each arm of AE (14/35 versus 11/31; P = 0.71), and remission in the per-protocol population (25/32 vs 18/27; P = 0.32). Overall, 8 soft tissue DFIs in the 10-day arm and 5 cases in the 20-day arm recurred as a new osteomyelitis [8/35 (23%) versus 5/31 (16%); P = 0.53]. Overall, the number of recurrences limited to the soft tissues was 4 (6%). By multivariate analysis, rates of remission (intention-to-treat population, hazard ratio 0.6, 95%CI 0.3-1.1; per-protocol population 0.8, 95%CI 0.4-1.5) and AE were not significantly different with a 10-day compared to 20-day course. CONCLUSIONS In this randomized, controlled pilot trial, post-debridement antibiotic therapy for soft tissue DFI for 10 days gave similar (and non-inferior) rates of remission and AEs to 20 days. A larger confirmatory trial is under way. TRIAL REGISTRATION ClinicalTrials NCT03615807.
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192
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Marconi L, Tedeschi S, Zamparini E, Terzi S, Rossi N, Boriani L, Trapani F, Giannella M, Ruinato DA, Marchionni E, Gasbarrini A, Viale P. Oral versus standard antimicrobial treatment for pyogenic native vertebral osteomyelitis: a single center, retrospective, propensity score balanced analysis. Open Forum Infect Dis 2022; 9:ofac366. [PMID: 35959206 PMCID: PMC9361174 DOI: 10.1093/ofid/ofac366] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 07/26/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Interest toward shorter antimicrobial regimens and oral treatment for osteoarticular infections is growing. The aim of this study is to assess whether there is an association between the administration of an entirely oral antibiotic therapy (OT) and the clinical outcome of native vertebral osteomyelitis (NVOs).
Methods
Single center, retrospective, observational study on consecutive patients with pyogenic NVOs over a 10-year period (2008-2018). Multivariate logistic regression analysis was carried out to identify risk factors for clinical failure, both in the whole population and in subgroups. The impact of OT versus standard treatment (intravenous induction followed by oral treatment whenever possible) was assessed in patients with a non-multidrug resistant microorganism (MDRO) etiology and the impact of a rifampin-containing regimen was assessed in patients affected by NVOs caused by staphylococci or of unknown etiology.
Results
Study population included 249 patients, 33 (13.3%) experienced clinical failure; OT group consisted of 54 patients (21.7%). Multivariate regression analysis of the whole population selected Charlson Comorbidity Index (aOR 1.291, 95% CI 1.114-1.497, p = 0.001) and MDRO etiology (aOR 3.301, 95% CI 1.368-7.964, p = 0.008) as independent factors for clinical failure. Among patients affected by a non-MDRO NVO, OT was not associated with an increased risk of clinical failure (aOR 0.487, 95% CI 0.133-1.782, p value = 0.271), even after adjustment for the propensity score of receiving OT. In the subgroup of patients with staphylococcal or unknown etiology NVO rifampin was independently associated with favorable outcome (aOR 0.315, 95% CI 0.105-0.949, p value = 0.040)
Conclusions
An entirely oral, highly bioavailable treatment, including rifampin, may be as effective as parenteral treatment in selected patients with NVOs.
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Affiliation(s)
- Lorenzo Marconi
- Infectious Disease Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Sara Tedeschi
- Correspondence: S. Tedeschi, MD, Department of Medical and Surgical Sciences, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy ()
| | - Eleonora Zamparini
- Infectious Disease Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Silvia Terzi
- Department of Oncological and Degenerative Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Nicolò Rossi
- Infectious Disease Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Luca Boriani
- Department of Oncological and Degenerative Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Filippo Trapani
- Infectious Disease Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Maddalena Giannella
- Infectious Disease Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | | | - Elisa Marchionni
- Infectious Disease Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Alessandro Gasbarrini
- Department of Oncological and Degenerative Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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193
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Clements MN, White IR, Copas AJ, Cornelius V, Cro S, Dunn DT, Quartagno M, Turner RM, Tweed CD, Walker AS. Improving clinical trial interpretation with ACCEPT analyses. NEJM EVIDENCE 2022; 1:evidctw2200018. [PMID: 35965674 PMCID: PMC7613267 DOI: 10.1056/evidctw2200018] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
| | | | | | | | - Suzie Cro
- Imperial Clinical Trials Unit, Imperial College London, London
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194
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Tai DBG, Berbari EF, Suh GA, Lahr BD, Abdel MP, Tande AJ. Truth in DAIR: Duration of Therapy and the Use of Quinolone/Rifampin-Based Regimens following Debridement and Implant Retention for Periprosthetic Joint Infections. Open Forum Infect Dis 2022; 9:ofac363. [PMID: 36072695 PMCID: PMC9439576 DOI: 10.1093/ofid/ofac363] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 07/21/2022] [Indexed: 11/17/2022] Open
Abstract
Background The optimal duration of antibiotic therapy after debridement and implant retention (DAIR) for periprosthetic joint infections (PJIs) is debated. Furthermore, the best antibiotic regimens for staphylococcal PJI are also unclear. In this study, we evaluated the impact of antibiotic therapy duration on the risk of failure. We assessed the utility of rifampin-based regimens for staphylococcal PJI managed with DAIR. Methods We performed a retrospective cohort study of patients 18 years and older diagnosed with hip and knee PJI who underwent DAIR between January 1, 2008 and 31 December 31, 2018 at Mayo Clinic, USA. The outcome was failure of DAIR. For statistical analysis, joint-stratified Cox regression models adjusted for age, sinus tract, symptom duration, and primary/revision arthroplasty were performed. Results We examined 247 cases of PJI with a median follow-up of 4.4 years (interquartile range [IQR], 2.3–7) after DAIR. The estimated 5-year cumulative incidence of failure was 28.1% (n = 65). There was no association between the duration of intravenous (IV) antibiotics (median 42 days; IQR, 38–42) and treatment failure (P = .119). A shorter duration of subsequent oral antibiotic therapy was associated with a higher risk of failure (P = .005; eg, 90-day vs 1-year duration; hazard ratio [HR], 3.50; 95% confidence interval [CI], 1.48–8.25). For staphylococcal knee PJI, both the use and longer duration of a rifampin-based regimen were associated with a lower risk of failure (both P = .025). There was no significant association between fluoroquinolone (FQ) use and failure (HR, 0.62; 95% CI, .31–1.24; P = .172). Conclusions The duration of initial IV antibiotic therapy did not correlate with treatment failure in this cohort of patients. Rifampin use is recommended for staphylococcal knee PJI. There was no apparent benefit of FQ use in staphylococcal PJI.
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Affiliation(s)
- Don Bambino Geno Tai
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine , Mayo Clinic , USA
| | - Elie F Berbari
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine , Mayo Clinic , USA
| | - Gina A Suh
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine , Mayo Clinic , USA
| | - Brian D Lahr
- Department of Quantitative Health Sciences , Mayo Clinic , USA
| | | | - Aaron J Tande
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine , Mayo Clinic , USA
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195
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Bohard L, Patry I, Sergent P, Leclerc G, Leroy J, Chirouze C, Bouiller K. Factors associated with late microbiological documentation of prosthetic joint infection. Future Microbiol 2022; 17:1115-1124. [PMID: 35860979 DOI: 10.2217/fmb-2021-0310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Purpose: To describe the number of prosthetic joint infections (PJIs) with late documentation and to identify associated factors. Methods: Bacterial PJIs with surgical management between November 2015 and November 2019 in a French center were analyzed. Results of short (72 h) and late culture (at 14 days) were analyzed. Results: A total of 160 PJIs were reported with 215 bacteria. Twenty-nine patients had late documentation (18.1%). The bacteria most involved were coagulase-negative staphylococci and Cutibacterium spp. (60%). In multivariate analysis, late chronic PJI (odds ratio = 2.47) and antibiotic therapy before surgery (odds ratio = 3.13) were associated with late-documented infection. Conclusion: A better knowledge of the factors associated with late-documented infections is essential in order to simplify antibiotic treatment at the appropriate time.
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Affiliation(s)
- Louis Bohard
- Department of Infectious Diseases, CHU Besancon, Besancon, 25000, France
| | - Isabelle Patry
- Department of Bacteriology, CHU Besancon, Besancon, 25000, France
| | - Pauline Sergent
- Department of Orthopedic, Trauma, Plastic & Reconstructive Surgery & Hand Clinic, CHU Besancon, Besancon, 25000, France
| | - Grégoire Leclerc
- Department of Orthopedic, Trauma, Plastic & Reconstructive Surgery & Hand Clinic, CHU Besancon, Besancon, 25000, France
| | - Joël Leroy
- Department of Infectious Diseases, CHU Besancon, Besancon, 25000, France
| | - Catherine Chirouze
- Department of Infectious Diseases, CHU Besancon, Besancon, 25000, France.,UMR-CNRS 6249 Chrono-Environnement, Université Bourgogne Franche-Comté, Besancon, Besancon, 25000, France
| | - Kevin Bouiller
- Department of Infectious Diseases, CHU Besancon, Besancon, 25000, France.,UMR-CNRS 6249 Chrono-Environnement, Université Bourgogne Franche-Comté, Besancon, Besancon, 25000, France
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196
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Halouska MA, Van Roy ZA, Lang AN, Hilbers J, Hewlett AL, Cortes-Penfield NW. Excellent Outcomes With the Selective Use of Oral Antibiotic Therapy for Bone and Joint Infections: A Single-Center Experience. Cureus 2022; 14:e26982. [PMID: 35989847 PMCID: PMC9385201 DOI: 10.7759/cureus.26982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background and objective Recent studies have challenged the notion that prolonged intravenous (IV) antibiotics are preferable to oral antibiotics for treating musculoskeletal infections. Our institution’s orthopedic surgery and orthopedic infectious disease (ID) groups have established consensus criteria for the use of oral antibiotics in musculoskeletal infections. In this study, we examine one-year and two-year outcomes of the selective use of oral antibiotics for musculoskeletal infections in a real-world setting. Methods We conducted a single-center retrospective analysis of adults seen in our orthopedic ID clinic over a six-month period for the first episode of surgically managed osteomyelitis, native joint septic arthritis (NJSA), prosthetic joint infection (PJI), or other musculoskeletal hardware infection with an established microbiologic etiology who received surgical interventions and >2 weeks of antimicrobial treatment. Patients were evaluated for treatment failure at one year and two years following their index surgery, which we defined as death, unplanned surgery, or the initiation of chronic antibiotic suppression. Results One-year treatment failure rates were 0/23 (0%) in patients who switched to oral therapy versus 6/17 (35%) in patients who remained on IV treatment. Two-year treatment failure rates were 0/23 (0%) in patients who switched to oral therapy versus 8/17 (47%) in patients who remained on IV treatment. Conclusions Our consensus criteria for the switch to oral antibiotics for musculoskeletal infections identified patients who went on to have excellent outcomes at one year and two years, suggesting that these criteria can effectively identify patients at low risk for treatment failure. Collaboration between ID specialists and orthopedic surgeons to select antimicrobial regimens can avoid significant burdens, costs, and complications associated with prolonged IV therapy.
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197
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Attwood LO, McKechnie M, Vujovic O, Higgs P, Lloyd‐Jones M, Doyle JS, Stewardson AJ. Review of management priorities for invasive infections in people who inject drugs: highlighting the need for patient-centred multidisciplinary care. Med J Aust 2022; 217:102-109. [PMID: 35754144 PMCID: PMC9539935 DOI: 10.5694/mja2.51623] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 05/18/2022] [Accepted: 05/30/2022] [Indexed: 09/26/2023]
Abstract
There has been a global increase in the burden of invasive infections in people who inject drugs (PWID). It is essential that patient-centred multidisciplinary care is provided in the management of these infections to engage PWID in care and deliver evidence-based management and preventive strategies. The multidisciplinary team should include infectious diseases, addictions medicine (inclusive of alcohol and other drug services), surgery, psychiatry, pain specialists, pharmacy, nursing staff, social work and peer support workers (where available) to help address the comorbid conditions that may have contributed to the patient's presentation. PWID have a range of antimicrobial delivery options that can be tailored in a patient-centred manner and thus are not limited to prolonged hospital admissions to receive intravenous antimicrobials for invasive infections. These options include discharge with outpatient parenteral antimicrobial therapy, long-acting lipoglycopeptides (dalbavancin and oritavancin) and early oral antimicrobials. Open and respectful discussion with PWID including around harm reduction strategies may decrease the risk of repeat presentations with injecting-related harms.
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Affiliation(s)
| | | | - Olga Vujovic
- Alfred HealthMelbourneVIC
- Monash UniversityMelbourneVIC
| | - Peter Higgs
- Burnet InstituteMelbourneVIC
- La Trobe UniversityMelbourneVIC
| | | | - Joseph S Doyle
- Alfred HealthMelbourneVIC
- Monash UniversityMelbourneVIC
- Burnet InstituteMelbourneVIC
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198
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Hoellwarth J, Reif T, Henry M, Miller A, Kaidi A, Rozbruch S. Unexpected positive intraoperative cultures (UPIC) at index osseointegration do not lead to increased postoperative infectious events. J Bone Jt Infect 2022; 7:155-162. [PMID: 35937089 PMCID: PMC9350876 DOI: 10.5194/jbji-7-155-2022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 02/28/2022] [Indexed: 11/11/2022] Open
Abstract
Introduction: The most common complication following transcutaneous
osseointegration for amputees is infection. Although an obvious source of
contamination is the permanent stoma, operative site contamination at the time
of implantation may be an additional source. This study investigates the impact
of unexpected positive intraoperative cultures (UPIC) on postoperative
infection. Methods: Charts were reviewed for 8 patients with UPIC
and 22 patients with negative intraoperative cultures (NIC) who had at least 1
year of post-osseointegration follow-up. All patients had 24 h of routine
postoperative antibiotic prophylaxis, with UPIC receiving additional antibiotics
guided by culture results. The main outcome measure was postoperative infection
intervention, which was graded as (0) none, (1) antibiotics unrelated to the
initial surgery, (2) operative debridement with implant retention, or (3)
implant removal. Results: The UPIC vs. NIC rate of infection
management was as follows: Grade 0, 6/8 = 75 % vs. 14/22 = 64 %, p= 0.682; Grade 1, 2/8 = 25 % vs. 8/22 = 36.4 % (Fisher's p= 0.682); Grade 2, 1/8 = 12.5 % vs. 0/22 = 0 % (Fisher's p= 0.267); Grade 3, 0/8 = 0 % vs. 1/22 = 4.5 % (Fisher's p= 1.000). No differences were statistically significant.
Conclusions: UPIC at index osseointegration, managed with
directed postoperative antibiotics, does not appear to increase the risk of
additional infection management. The therapeutic benefit of providing additional
directed antibiotics versus no additional antibiotics following UPIC is unknown
and did not appear to increase the risk of other adverse outcomes in our
cohort.
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Affiliation(s)
- Jason S. Hoellwarth
- Limb Lengthening and Complex Reconstruction Service, Hospital for
Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New
York, NY 10021, USA
| | - Taylor J. Reif
- Limb Lengthening and Complex Reconstruction Service, Hospital for
Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New
York, NY 10021, USA
| | - Michael W. Henry
- Infectious Disease Service, Hospital for Special Surgery, Weill
Cornell Medical College, 535 East 70th Street, New York, NY 10021,
USA
| | - Andy O. Miller
- Infectious Disease Service, Hospital for Special Surgery, Weill
Cornell Medical College, 535 East 70th Street, New York, NY 10021,
USA
| | - Austin C. Kaidi
- Limb Lengthening and Complex Reconstruction Service, Hospital for
Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New
York, NY 10021, USA
| | - S. Robert Rozbruch
- Limb Lengthening and Complex Reconstruction Service, Hospital for
Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New
York, NY 10021, USA
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199
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Richebé P, Coiffier G, Guggenbuhl P, Mulleman D, Couderc M, Dernis E, Deprez V, Salliot C, Urien S, Brault R, Ruyssen-Witrand A, Hoppe E, Chatelus E, Roux CH, Ottaviani S, Baufrere M, Michaut A, Pauvele L, Darrieutort-Laffite C, Wendling D, Coquerelle P, Bart G, Gervais E, Goeb V, Ardizzone M, Pertuiset E, Derolez S, Ziza JM, Flipo RM, Godot S, Seror R. Management and outcome of native joint septic arthritis: a nationwide survey in French rheumatology departments, 2016-2017. Ann Rheum Dis 2022; 81:annrheumdis-2022-222143. [PMID: 35820674 DOI: 10.1136/ard-2022-222143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 06/24/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To describe current management and outcome of native joint septic arthritis (NJSA) in French rheumatology departments. METHODS For this retrospective, nationwide multicentric study, 127 French rheumatology departments were contacted to report up to 12 cases of NJSA that occurred between 1 January 2016 and 31 December 2017. Characteristics, diagnosis procedures, therapeutic management and outcome were recorded. RESULTS Overall, 362 patients were included (mean age 64.0±18.6 years, median Charlson comorbidity index 3.5 (0-14)). Knee was the most frequent site (n=160 (38.9%)), and Staphylococcus sp (n=185 (51.4%)), the most frequent pathogen. All patients received antibiotics for a mean duration of 46.8 (±22.0) days, including intravenous route for a mean of 17.2 (±15.4) days. Management was heterogeneous. Surgical procedure was performed in 171 (48.3%), joint immobilisation in 128 (43.8%). During follow-up, 91 (28.3%) patients have had serious complications and 28 (9.2%) of them died. Factors associated with 1-year mortality were age (OR 1.08, 95% CI 1.04 to 1.13; p<0.001), Charlson's index (OR 1.30, 95% CI 1.06 to 1.58; p=0.012), presence of bacteraemia (OR 4.02, 95% CI 1.35 to 11.99; p=0.008), antibiotic use in the previous 3 months (OR 3.32, 95% CI 1.11 to 9.87; p=0.029) and Staphylococcus aureus NJSA compared with Streptococcus sp. NJSA (OR 7.24, 95% CI 1.26 to 41.68, p=0.027). The complete recovery with no adverse joint outcome at 1 year was observed in n=125/278 patients (55.0%). CONCLUSION Prognosis of NJSA remained severe with a high rate of morbimortality. Its management was very heterogeneous. This study highlights the importance of the new French recommendations, published after the completion of the study, in order to facilitate NJSA management.
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Affiliation(s)
- Pauline Richebé
- Service de rhumatologie, Hôpitaux universitaires Paris-Sud, Le Kremlin-Bicetre, France
| | - Guillaume Coiffier
- Service de Rhumatologie, GHT Rance-Emeraude, CH Dinan et Saint-Malo, France, Dinan, France
| | - Pascal Guggenbuhl
- Service de Rhumatologie, CHU Rennes Univ Rennes, INSERM UMR 1241, Institut NUMECAN (Nutrition Metabolisms and Cancer), F-35000 Rennes, France, Rennes, France
| | - Denis Mulleman
- Service de rhumatologie, Centre de Référence en Infections Ostéo-Articulaires Complexes du grand Ouest, CHRU de Tours, Tours, France
| | - Marion Couderc
- Rheumatology, CHU Gabriel Montpied, Clermont-Ferrand, France
| | | | - Valentine Deprez
- Rheumatology, Centre Hospitalier Universitaire Amiens-Picardie, Amiens, France
| | - Carine Salliot
- Rheumatology, Nouvel Hôpital d'Orléans CHRO La Source, Orleans, France
| | - Saik Urien
- INSERN et Unité de recherche clinique, Site Tarnier (hôpital Cochin), Paris, France
| | - Rachel Brault
- Service rhumatologie, CHU Poitiers, Poitiers, France
| | | | | | - Emmanuel Chatelus
- Rheumatology, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | | | | | - Marie Baufrere
- Rheumatology, Hôpital Ambroise-Pare, Boulogne-Billancourt, France
| | - Alexia Michaut
- Centre Hospitalier Départemental Vendée Hôpital de Montaigu, Montaigu, France
| | - Loic Pauvele
- Rheumatology, Centre Hospitalier Universitaire de Reims Hôpital d'enfants, Reims, France
| | | | | | | | | | | | | | - Marc Ardizzone
- Rheumatology, Centre Hospitalier de Mulhouse, Mulhouse, France
| | | | - Sophie Derolez
- Rheumatology, Hôpital Bicêtre, Le Kremlin-Bicetre, France
| | - Jean Marc Ziza
- Rheumatology, Hôpital de la Croix Saint-Simon, Paris, France
| | - René-Marc Flipo
- Service de Rhumatologie, CHU Roger Salengro, Université de Lille, Lille, France
| | - Sophie Godot
- Rheumatology, Hôpital de la Croix Saint-Simon, Paris, France
| | - Raphaele Seror
- Rheumatology, Hôpitaux universitaires Paris-Sud, Le Kremlin Bicêtre, France
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200
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Johnson MD, Davis AP, Dyer AP, Jones TM, Spires SS, Ashley ED. Top Myths of Diagnosis and Management of Infectious Diseases in Hospital Medicine. Am J Med 2022; 135:828-835. [PMID: 35367180 DOI: 10.1016/j.amjmed.2022.03.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 02/28/2022] [Accepted: 03/02/2022] [Indexed: 11/01/2022]
Abstract
Antimicrobial agents are among the most frequently prescribed medications during hospitalization. However, approximately 30% to 50% or more of inpatient antimicrobial use is unnecessary or suboptimal. Herein, we describe 10 common myths of diagnosis and management that often occur in the hospital setting. Further, we discuss supporting data to dispel each of these myths. This analysis will provide hospitalists and other clinicians with a foundation for rational decision-making about antimicrobial use and support antimicrobial stewardship efforts at both the patient and institutional levels.
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Affiliation(s)
- Melissa D Johnson
- Duke Antimicrobial Stewardship Outreach Network (DASON), Duke University Medical Center, Durham, NC.
| | - Angelina P Davis
- Duke Antimicrobial Stewardship Outreach Network (DASON), Duke University Medical Center, Durham, NC
| | - April P Dyer
- Duke Antimicrobial Stewardship Outreach Network (DASON), Duke University Medical Center, Durham, NC
| | - Travis M Jones
- Duke Antimicrobial Stewardship Outreach Network (DASON), Duke University Medical Center, Durham, NC
| | - S Shaefer Spires
- Duke Antimicrobial Stewardship Outreach Network (DASON), Duke University Medical Center, Durham, NC
| | - Elizabeth Dodds Ashley
- Duke Antimicrobial Stewardship Outreach Network (DASON), Duke University Medical Center, Durham, NC
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