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Ferris A. Should bone biopsy be the standard for suspected osteomyelitis in patients with pressure ulcers? J Wound Care 2024; 33:202-206. [PMID: 38451792 DOI: 10.12968/jowc.2024.33.3.202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
DECLARATION OF INTEREST The author has no conflicts of interest to declare.
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Affiliation(s)
- Amy Ferris
- Department of Wound Healing, University Hospital of Wales, Cardiff
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2
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Uçkay I, Wirth S, Zörner B, Fucentese S, Wieser K, Schweizer A, Müller D, Zingg P, Farshad M. Study protocol: short against long antibiotic therapy for infected orthopedic sites - the randomized-controlled SALATIO trials. Trials 2023; 24:117. [PMID: 36803837 PMCID: PMC9938993 DOI: 10.1186/s13063-023-07141-2] [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: 10/01/2022] [Accepted: 02/07/2023] [Indexed: 02/20/2023] Open
Abstract
BACKGROUND Few studies address the appropriate duration of post-surgical antibiotic therapy for orthopedic infections; with or without infected residual implants. We perform two similar randomized-clinical trials (RCT) to reduce the antibiotic use and associated adverse events. METHODS Two unblinded RCTs in adult patients (non-inferiority with a margin of 10%, a power of 80%) with the primary outcomes "remission" and "microbiologically-identical recurrences" after a combined surgical and antibiotic therapy. The main secondary outcome is antibiotic-related adverse events. The RCTs allocate the participants between 3 vs. 6 weeks of post-surgical systemic antibiotic therapy for implant-free infections and between 6 vs. 12 weeks for residual implant-related infections. We need a total of 280 episodes (randomization schemes 1:1) with a minimal follow-up of 12 months. We perform two interim analyses starting approximately after 1 and 2 years. The study approximatively lasts 3 years. DISCUSSION Both parallel RCTs will enable to prescribe less antibiotics for future orthopedic infections in adult patients. TRIAL REGISTRATION ClinicalTrial.gov NCT05499481. Registered on 12 August 2022. PROTOCOL VERSION 2 (19 May 2022).
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Affiliation(s)
- Ilker Uçkay
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland. .,Unit for Clinical and Applied Research, Balgrist University Hospital, University of Zurich, Zurich, Switzerland. .,Infectiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.
| | - Stephan Wirth
- grid.7400.30000 0004 1937 0650Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Björn Zörner
- grid.7400.30000 0004 1937 0650Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Sandro Fucentese
- grid.7400.30000 0004 1937 0650Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Karl Wieser
- grid.7400.30000 0004 1937 0650Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Andreas Schweizer
- grid.7400.30000 0004 1937 0650Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland ,grid.7400.30000 0004 1937 0650Hand Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Daniel Müller
- grid.7400.30000 0004 1937 0650Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Patrick Zingg
- grid.7400.30000 0004 1937 0650Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Mazda Farshad
- grid.7400.30000 0004 1937 0650Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland ,grid.7400.30000 0004 1937 0650Medical Direction, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Damioli L, Shepard Z, Wilson MP, Erlandson KM. Retrospective analysis of the management of pelvic decubitus ulcers and their outcomes. Ther Adv Infect Dis 2023; 10:20499361231196664. [PMID: 37693861 PMCID: PMC10483971 DOI: 10.1177/20499361231196664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 08/07/2023] [Indexed: 09/12/2023] Open
Abstract
Background Many patients with decubitus-related osteomyelitis are ineligible for myocutaneous flapping, and optimal management in this population is unknown. We describe treatments and outcomes of hospitalized patients with decubitus ulcer-related osteomyelitis who did not undergo surgical reconstruction or coverage. Methods We systematically identified hospitalized patients with diagnoses of pelvic, sacral, or femoral osteomyelitis due to decubitus ulceration between 1 January 2018 and 31 December 2018. Demographics, comorbidities, laboratory data, and outcomes were collected by manual chart review. T-tests or Chi-square tests were used for descriptive statistical comparisons; logistic regressions were used to explore the odds of readmission, osteomyelitis-related readmission, and death. Results Of 89 patients meeting inclusion criteria, 34 (38%) received surgical debridement and ⩾6 weeks of antibiotics; 55 (62%) received either antibiotics alone or debridement and <6 weeks of antibiotics. Mean age was 55 (standard deviation 18) years, 55% of patients were male, and 69% had spinal cord injury or other form of paralysis. Within 1 year, 56 (63%) patients were readmitted, 38 (44%) patients were readmitted due to complications from osteomyelitis, and 15 (17%) died. We found no significant differences in readmission (OR = 1.33, 95% CI: 0.54-3.21, p = 0.53), readmission related to osteomyelitis (OR = 1.64, 95% CI: 0.69-4.04, p = 0.27), subsequent sepsis (OR = 2.27, 95% CI: 0.83-6.93, p = 0.13), or death (OR = 2.88, 95% CI: 0.83-13.4, p = 0.12) by treatment group. Conclusions Among patients with decubitus-related osteomyelitis who did not undergo myocutaneous flapping, outcomes were generally poor regardless of treatment, and not significantly improved with prolonged antibiotics. Prospective studies are needed to assess best practice strategies for this challenging patient population.
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Affiliation(s)
- Laura Damioli
- Infectious Disease Division, University of Colorado Hospital, 12700 E. 19th Avenue B-168, Research Complex 2 Building, Aurora, CO 80045, USA
| | - Zachary Shepard
- Division of Infectious Diseases, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Melissa P. Wilson
- Department of Bioinformatics and Personalized Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kristine M. Erlandson
- Division of Infectious Diseases, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
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Prognostic Evaluation of Pressure Sore Surgery Index: Risk Assessment and Outcomes of a Retrospective Cohort Study. Plast Reconstr Surg 2021; 149:483-493. [PMID: 34898527 DOI: 10.1097/prs.0000000000008766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Complication rates of up to 46 percent are reported following pressure sore surgery. Pressure sore patients often exhibit ineffective postoperative wound healing despite tension-free flap coverage, necessitating surgical revision and prolonged hospitalization. Rather than pressure sore recurrence, such impaired healing reflects a failed progress through the physiologic stages of the normal wound-healing cascade. The principal objective of the study reported here was to elucidate potentially modifiable inherent variables that predict predisposition to impaired healing and to provide a tool for identifying cases at risk for complicated early postoperative recovery following pressure sore reconstruction. METHODS A retrospective chart review of late-stage (stage 3 or higher) sacral and ischial pressure sore patients who underwent flap reconstruction from 2014 to 2019 was performed. A multivariable logistic regression model was used to identify key patient and operative factors predictive of impaired healing. Furthermore, the Prognostic Evaluation of Pressure Sore Surgery Index (PEPSI) was established based on the identified risk factors. RESULTS In a cohort of 121 patients, 36 percent exhibited impaired healing. Of these, 34 patients suffered from dehiscences, necessitating surgical revision. Statistically significant risk factors comprising late recurrence (OR, 3.8), immobility (OR, 12.4), greater surface (>5 cm diameter; OR, 7.3), and inhibited thrombocytes (aspirin monotherapy; OR, 5.7) were combined to formulate a prognostic scoring system (PEPSI-LIGhT). CONCLUSIONS The PEPSI-LIGhT system serves as a prognostic instrument for assessing individual risk for impaired healing in pressure sore patients. Preoperative risk stratification supports rational decision-making regarding operative candidacy, allows evidence-based patient counseling, and supports the implementation of individualized treatment protocols. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Richtr P, Hoch J, Svobodová K, Zbyněk Jech, Kříž J, Hyšperská V, Štulík J, Marek B, Přikryl P. Hemicorporectomy - the ultimate solution of terminal pelvic sepsis. Acta Chir Belg 2021; 121:432-436. [PMID: 31986986 DOI: 10.1080/00015458.2020.1722930] [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: 10/25/2022]
Abstract
Hemicorporectomy is the amputation of the lower body - pelvis and lower limbs. It requires transection of the spine and dural sac at the level of aortic bifurcation and inferior lower vein, and permanent urinary and stool derivation. Performance indications are tumour trauma and terminal pelvic osteomyelitis. So far about 60 cases have been published; only 11 operations were performed for terminal osteomyelitis. We have successfully performed hemicorporectomy in a patient with chronic sepsis from terminal pelvic osteomyelitis after exhausting all other treatment options. The experience gained and the important moments of the procedure are given in the case report.
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Affiliation(s)
- Patrik Richtr
- Department of Surgery, Second Faculty of Medicine, Charles University and Teaching Hospital Motol, Prague, Czech Republic
| | - Jiří Hoch
- Department of Surgery, Second Faculty of Medicine, Charles University and Teaching Hospital Motol, Prague, Czech Republic
| | - Karolína Svobodová
- Department of Surgery, Second Faculty of Medicine, Charles University and Teaching Hospital Motol, Prague, Czech Republic
| | - Zbyněk Jech
- Department of Surgery, Second Faculty of Medicine, Charles University and Teaching Hospital Motol, Prague, Czech Republic
| | - Jiří Kříž
- Spinal Unit, Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University and Teaching Hospital Motol, Prague, Czech Republic
| | - Veronika Hyšperská
- Spinal Unit, Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University and Teaching Hospital Motol, Prague, Czech Republic
| | - Jan Štulík
- Department of Spondylosurgery, First Faculty of Medicine, Charles University and Teaching Hospital Motol, Prague, Czech Republic
| | - Babjuk Marek
- Department of Urology, Second Faculty of Medicine, Charles University and Teaching Hospital Motol, Prague, Czech Republic
| | - Petr Přikryl
- Department of Anesthesia Resuscitation and Intensive Medicine, Second Faculty of Medicine, Charles University and Teaching Hospital Motol, Prague, Czech Republic
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Crespo A, Stevens NM, Chiu E, Pham V, Leucht P. Incidence of Osteomyelitis in Sacral Decubitus Ulcers and Recommendations for Management. JBJS Rev 2021; 8:e0187. [PMID: 33006456 DOI: 10.2106/jbjs.rvw.19.00187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Stage-4 pressure ulcers are defined as ulcerations that violate the fascia and expose underlying bone, muscle, and tendon. Exposed bone is always colonized by bacteria, but this does not necessarily lead to osteomyelitis. The rates of osteomyelitis in exposed bone in stage-4 pressure ulcers range from 14% to 86%.There has been no evidence that the presence of osteomyelitis leads to higher complication rates following flap coverage. There has been no evidence that bone biopsy and preoperative treatment of osteomyelitis have any benefit before flap coverage.
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Affiliation(s)
- Alexander Crespo
- NYU Langone Orthopedics (A.C., N.M.S., and P.L.), NYU Langone Plastic Surgery Associates (E.C.), and Division of Infectious Diseases and Immunology (V.P.), NYU Langone Health, New York, NY
| | - Nicole M Stevens
- NYU Langone Orthopedics (A.C., N.M.S., and P.L.), NYU Langone Plastic Surgery Associates (E.C.), and Division of Infectious Diseases and Immunology (V.P.), NYU Langone Health, New York, NY
| | - Ernest Chiu
- NYU Langone Orthopedics (A.C., N.M.S., and P.L.), NYU Langone Plastic Surgery Associates (E.C.), and Division of Infectious Diseases and Immunology (V.P.), NYU Langone Health, New York, NY
| | - Vinh Pham
- NYU Langone Orthopedics (A.C., N.M.S., and P.L.), NYU Langone Plastic Surgery Associates (E.C.), and Division of Infectious Diseases and Immunology (V.P.), NYU Langone Health, New York, NY
| | - Philipp Leucht
- NYU Langone Orthopedics (A.C., N.M.S., and P.L.), NYU Langone Plastic Surgery Associates (E.C.), and Division of Infectious Diseases and Immunology (V.P.), NYU Langone Health, New York, NY.,Department of Cell Biology, NYU School of Medicine, New York, NY
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7
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Uçkay I, Holy D, Betz M, Sauer R, Huber T, Burkhard J. Osteoarticular infections: a specific program for older patients? Aging Clin Exp Res 2021; 33:703-710. [PMID: 31494913 DOI: 10.1007/s40520-019-01329-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 08/16/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND With the increasing number of elderly patients, arthroplasties, fractures and diabetic foot infections, the worldwide number of osteoarticular infections (OAI) among the elderly is concomitantly expected to rise. AIMS We explore existing scientific knowledge about OAI in the frail elderly population. METHODS We performed a literature search linking OAIs to geriatric patients and comparing elderly patients (> 65 years) with average adults (range 18-65 years). RESULTS In this literature, financial aspects, comparison of diverse therapies on quality of life, reimbursement policies, or specific guidelines or nursing recommendations are missing. Age itself was not an independent factor related to particular pathogens, prevention of OAI, nursing care, and outcomes of OAI. However, geriatric patients were significantly more exposed to adverse events of therapy. They had more co-morbidities and more conservative surgery for OAI. CONCLUSION Available literature regarding OAI management among elderly patients is sparse. In recent evaluations, age itself does not seem an independent factor related to particular epidemiology, pathogens, prevention, nursing care, rehabilitation and therapeutic outcomes of OAI. Future clinical research will concern more conservative surgical indications, but certainly reduce inappropriate antibiotic use.
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Affiliation(s)
- Ilker Uçkay
- Infectiology, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland.
- Infection Control, Balgrist University Hospital, Zurich, Switzerland.
| | - Dominique Holy
- Internal Medicine, Balgrist University Hospital, Zurich, Switzerland
| | - Michael Betz
- Orthopaedic Surgery, Balgrist University Hospital, Zurich, Switzerland
| | - Regina Sauer
- Nursing Care, Balgrist University Hospital, Zurich, Switzerland
| | - Tanja Huber
- Pharmacy, Balgrist University Hospital, Zurich, Switzerland
| | - Jan Burkhard
- Infection Control, Balgrist University Hospital, Zurich, Switzerland
- Internal Medicine, Balgrist University Hospital, Zurich, Switzerland
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Colosimo C, Fredericks C, Yon JR, Kubasiak JC, Bokhari F, Poulakidas S. Damage control hip disarticulation: two-stage operation with index creation of a large medial flap for the septic hip. Trauma Surg Acute Care Open 2020; 5:e000502. [PMID: 32923682 PMCID: PMC7467553 DOI: 10.1136/tsaco-2020-000502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/11/2020] [Accepted: 08/05/2020] [Indexed: 01/09/2023] Open
Abstract
Background Although rarely performed, hip disarticulation (HD) is usually used for the patient with a non-viable leg who is also in extremis. HD was first used for trauma and infection; however, the technique was perfected during the age of hindquarter amputation for osteosarcomas. The operation performed by most surgeons today is still based on the oncological principles of high vessel control and ligation. When this approach has been used in the overwhelmingly infected or mangled extremity, it has resulted in high mortality rates. During the last 20 years, the concept of damage control operation has been embraced by emergency surgeons in all fields. We sought to extrapolate this concept and to apply it to the non-viable lower extremity. Methods We describe a new concept of damage control HD, review the technique and discuss our consecutive series of nine patients who underwent the procedure for trauma or necrotizing infection without flap dehiscence or mortality. Results All patients survived to hospital discharge. At time of discharge or at follow-up, six of the nine patients were able to transfer to a wheelchair. Discussion Proper disarticulations for infection need to address these two operative and postoperative issues: damage control debridement with creation of sufficient flap size and thorough postoperative wound care.Level IV.
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Affiliation(s)
- Christina Colosimo
- Department of Trauma, Sky Ridge Medical Center, Lone Tree, Colorado, USA
| | - Charles Fredericks
- Department of General Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - James R Yon
- Department of Trauma and Acute Care Surgery, Swedish Medical Center, Englewood, Colorado, USA
| | - John C Kubasiak
- Department of General Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Faran Bokhari
- Department of Trauma And Burn, John H Stroger Hospital of Cook County, Chicago, Illinois, USA
| | - Stathis Poulakidas
- Department of Trauma And Burn, John H Stroger Hospital of Cook County, Chicago, Illinois, USA
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9
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Duan H, Li H, Liu H, Zhang H, Liu N, Dong Q, Li Z. Extracorporeal shockwave therapy combined with alginate dressing for treatment of sacroiliac decubital necrosis in older adults: A case report. Medicine (Baltimore) 2020; 99:e19849. [PMID: 32384429 PMCID: PMC7220157 DOI: 10.1097/md.0000000000019849] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
RATIONALE Pressure sores are major clinical problems with limited treatment options. PATIENT CONCERN A 62-year-old man, admitted with unresponsive, indifferent mood, and malnutrition. A noval-shaped skin lesion deeping into the fascia was found in the sacrococcygeal region. DIAGNOSIS The patient was diagnosed with delayed carbon monoxide poisoning encephalopathy and stage IV sacrococcygeal pressure sores. INTERVENTION The patient received neurologic rehabilitation therapy and simple debridement dressing care followed by extracorporeal shockwave therapy. OUTCOMES The scores for the pressure ulcer healing scale were 17 points, 13 points, 9 points, and 5 points, respectively, before treatment and at the 4-, 8-, and 12-week follow-ups. At 2 weeks after discharging the total pressure ulcer healing scale score was 0, which signifies that the sacroiliac decubital necrosis healed without adverse reactions and side effects. LESSONS This study presents a therapeutic solution for treating older adults with pressure ulcers by using extracorporeal shockwave with alginate dressing, which proved effective and safe.
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Russell CD, Tsang STJ, Simpson AHRW, Sutherland RK. Outcomes, Microbiology and Antimicrobial Usage in Pressure Ulcer-Related Pelvic Osteomyelitis: Messages for Clinical Practice. J Bone Jt Infect 2020; 5:67-75. [PMID: 32455097 PMCID: PMC7242403 DOI: 10.7150/jbji.41779] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 12/27/2019] [Indexed: 12/16/2022] Open
Abstract
Introduction: Pressure ulcer-related pelvic osteomyelitis is a relatively under-studied entity in the field of bone infection. We sought to add to the limited evidence base for managing this challenging syndrome. Methods: Cases were identified retrospectively from a surgical database and hospital discharge codes at a U.K. tertiary centre (2009-2018). Risk factors associated with outcomes were analysed by logistic regression. Results: We identified 35 patients (mean age 57.4 years), 69% managed with a combined medical and surgical approach, with mean follow-up of 3.7 years from index admission. Treatment failure (requiring further surgery or intravenous antimicrobials) occurred in 71% and eventual ulcer healing in 36%. One-year mortality was 23%. Lack of formal care support on discharge, post-traumatic (asensate) neurological deficit and index CRP (>184mg/L) were associated with treatment failure (p=0.001). Age (>59.5 years), lack of attempted soft tissue coverage, haemoglobin (<111g/L) and albumin (<25g/L) were associated with non-healing ulcers (p=0.003). Superficial wound swabs had low sensitivity and specificity compared to deep bone microbiology. Infection (based on deep bone microbiology from 46 infection episodes) was usually polymicrobial (87%), commonly involving S. aureus, Enterococci, GNB and anaerobes. Antimicrobial duration ranged from 0-103 days (mean 54) and was not associated with subsequent treatment failure. Conclusions: Attempted soft tissue coverage after surgical debridement, ensuring appropriate support for personal care after discharge and nutritional optimisation could improve outcomes. Superficial wound swabs are uninformative and deep bone sampling should be pursued. Long antimicrobial courses do not improve outcomes. Clinicians should engage patients in anticipatory care planning.
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Affiliation(s)
- Clark D Russell
- NHS Lothian Infection Service, Regional Infectious Diseases Unit, Western General Hospital, Edinburgh, U.K.,University of Edinburgh Centre for Inflammation Research, Queen's Medical Research Institute, Edinburgh BioQuarter, Edinburgh, U.K
| | - Shao-Ting Jerry Tsang
- University of Edinburgh Centre for Inflammation Research, Queen's Medical Research Institute, Edinburgh BioQuarter, Edinburgh, U.K.,Department of Orthopaedic Surgery, University of Edinburgh, Chancellor's Building, Edinburgh, U.K
| | | | - Rebecca K Sutherland
- NHS Lothian Infection Service, Regional Infectious Diseases Unit, Western General Hospital, Edinburgh, U.K
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11
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Betz M, Uçkay I, Schüpbach R, Gröber T, Botter SM, Burkhard J, Holy D, Achermann Y, Farshad M. Short postsurgical antibiotic therapy for spinal infections: protocol of prospective, randomized, unblinded, noninferiority trials (SASI trials). Trials 2020; 21:144. [PMID: 32028985 PMCID: PMC7006138 DOI: 10.1186/s13063-020-4047-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 01/02/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND There are several open scientific questions regarding the optimal antibiotic treatment of spinal infections (SIs) with or without an implant. The duration of postsurgical antibiotic therapy is debated. METHODS We will perform two unblinded randomized controlled trials (RCTs). We hypothesize that shorter durations of systemic antibiotic therapy after surgery for SI are noninferior (10% margin, 80% power, α = 5%) to existing (long) treatment durations. The RCTs allocate the participants to two arms of 2 × 59 episodes each: 3 vs. 6 weeks of targeted postsurgical systemic antibiotic therapy for implant-free SIs or 6 vs. 12 weeks for implant-related SIs. This equals a total of 236 adult SI episodes (randomization scheme 1:1) with a minimal follow-up of 12 months. All participants receive concomitant multidisciplinary surgical, re-educational, internist, and infectious disease care. We will perform three interim analyses that are evaluated, in a blinded analysis, by an independent study data monitoring committee. Besides the primary outcome of remission, we will also assess adverse events of antibiotic therapy, changes of the patient's nutritional status, the influence of immune suppression, total costs, functional scores, and the timely evolution of the (surgical) wounds. We define infection as the presence of local signs of inflammation (pus, wound discharge, calor, and rubor) together with microbiological evidence of the same pathogen(s) in at least two intraoperative samples, and we define remission as the absence of clinical, laboratory, and/or radiological evidence of (former or new) infection. DISCUSSION Provided that there is adequate surgical debridement, both RCTs will potentially enable prescription of less antibiotics during the therapy of SI, with potentially less adverse events and reduced overall costs. TRIAL REGISTRATION ClinicalTrials.gov, NCT04048304. Registered on 5 August 2019. PROTOCOL VERSION 2, 5 July 2019.
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Affiliation(s)
- Michael Betz
- Department of Orthopedic Surgery, Balgrist University Hospital, Zurich, Switzerland.,University Spine Center Zürich, Balgrist University Hospital, Zurich, Switzerland
| | - Ilker Uçkay
- Unit for Clinical and Applied Research, Balgrist University Hospital, Zurich, Switzerland. .,Infectiology, Balgrist University Hospital, Zurich, Switzerland. .,Internal Medicine, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Regula Schüpbach
- Unit for Clinical and Applied Research, Balgrist University Hospital, Zurich, Switzerland
| | - Tanja Gröber
- Unit for Clinical and Applied Research, Balgrist University Hospital, Zurich, Switzerland
| | - Sander M Botter
- Swiss Center for Muskuloskeletal Banking, Balgrist Campus AG, Zurich, Switzerland
| | - Jan Burkhard
- Internal Medicine, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Dominique Holy
- Internal Medicine, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Yvonne Achermann
- Infectiology, Balgrist University Hospital, Zurich, Switzerland.,Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
| | - Mazda Farshad
- Department of Orthopedic Surgery, Balgrist University Hospital, Zurich, Switzerland.,University Spine Center Zürich, Balgrist University Hospital, Zurich, Switzerland
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12
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Wong D, Holtom P, Spellberg B. Osteomyelitis Complicating Sacral Pressure Ulcers: Whether or Not to Treat With Antibiotic Therapy. Clin Infect Dis 2019; 68:338-342. [PMID: 29986022 PMCID: PMC6594415 DOI: 10.1093/cid/ciy559] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 07/06/2018] [Indexed: 12/19/2022] Open
Abstract
The treatment of osteomyelitis in patients with stage IV sacral pressure ulcers is controversial. We conducted a systematic literature review and did not find evidence of benefit of antibacterial therapy in this setting without concomitant surgical debridement and wound coverage. Furthermore, many patients with chronically exposed bone do not have evidence of osteomyelitis when biopsied, and magnetic resonance imaging may not accurately distinguish osteomyelitis from bone remodeling. The goal of therapy should be local wound care and assessment for the potential of wound closure. If the wound can be closed and osteomyelitis is present on bone biopsy, appropriate antibiotic therapy is reasonable. We find no data to support antibiotic durations of >6 weeks in this setting, and some authors recommend 2 weeks of therapy if the osteomyelitis is limited to cortical bone. If the wound will not be closed, we find no clear evidence supporting a role for antibiotic therapy.
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Affiliation(s)
- Darren Wong
- Division of Infectious Diseases, Keck School of Medicine, University of Southern California (USC)
| | - Paul Holtom
- Division of Infectious Diseases, Keck School of Medicine, University of Southern California (USC)
- Los Angeles County + USC Medical Center, California
| | - Brad Spellberg
- Division of Infectious Diseases, Keck School of Medicine, University of Southern California (USC)
- Los Angeles County + USC Medical Center, California
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13
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Esposito S, Ascione T, Pagliano P. Management of bacterial skin and skin structure infections with polymicrobial etiology. Expert Rev Anti Infect Ther 2018; 17:17-25. [PMID: 30518267 DOI: 10.1080/14787210.2019.1552518] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Skin and Soft Tissue Infections (SSTIs) are some of the most commonly occurring bacterial infections, with a wide range of possible etiological pathogens and a considerable variety of clinical presentations and severity; from mild to severe life-threatening infections. Several classifications have been proposed based on a specific variable, such as anatomical localization, skin extension, progression rate, clinical presentation, severity, and etiological agent. Areas covered: The last criteria allows the differentiation of SSTIs as monomicrobial and polymicrobial. Among them, especially those infections with a long lasting or chronic course can be sustained by multiple microbial etiology. Most polymicrobial SSTIs can be included in the following: diabetes foot infections (DFIs), pressure ulcers infection, burn infection, and infected chronic ulcers. Expert commentary: The medical management of these infections comprises the administration of wide a spectrum antibiotic, taking into consideration the frequent occurrence of multidrug resistant microorganisms as responsible agents. An appropriate deep tissue specimen for microbiological examination is a very important issue, especially for polymicrobial infections, sometimes permitting the distinction between real pathogens and contaminants avoiding more complex antibiotic treatments. This aspect must be strongly emphasized, as frequently superficial swabs remain the specimen of choice because they are easy to obtain.
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Affiliation(s)
- Silvano Esposito
- a Departement of Infectious Diseases , University of Salerno , Salerno , Italy
| | - Tiziana Ascione
- b Department of Infectious Diseases , AORN dei Colli , Naples , Italy
| | - Pasquale Pagliano
- b Department of Infectious Diseases , AORN dei Colli , Naples , Italy
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Andrianasolo J, Ferry T, Boucher F, Chateau J, Shipkov H, Daoud F, Braun E, Triffault-Fillit C, Perpoint T, Laurent F, Mojallal AA, Chidiac C, Valour F. Pressure ulcer-related pelvic osteomyelitis: evaluation of a two-stage surgical strategy (debridement, negative pressure therapy and flap coverage) with prolonged antimicrobial therapy. BMC Infect Dis 2018; 18:166. [PMID: 29636030 PMCID: PMC5894174 DOI: 10.1186/s12879-018-3076-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Accepted: 04/03/2018] [Indexed: 01/27/2023] Open
Abstract
Background A two-stage surgical strategy (debridement-negative pressure therapy (NPT) and flap coverage) with prolonged antimicrobial therapy is usually proposed in pressure ulcer-related pelvic osteomyelitis but has not been widely evaluated. Methods Adult patients with pressure ulcer-related pelvic osteomyelitis treated by a two-stage surgical strategy were included in a retrospective cohort study. Determinants of superinfection (i.e., additional microbiological findings at reconstruction) and treatment failure were assessed using binary logistic regression and Kaplan-Meier curve analysis. Results Sixty-four pressure ulcer-related pelvic osteomyelitis in 61 patients (age, 47 (IQR, 36–63)) were included. Osteomyelitis was mostly polymicrobial (73%), with a predominance of S. aureus (47%), Enterobacteriaceae spp. (44%) and anaerobes (44%). Flap coverage was performed after 7 (IQR, 5–10) weeks of NPT, with 43 (68%) positive bone samples among which 39 (91%) were superinfections, associated with a high ASA score (OR, 5.8; p = 0.022). An increased prevalence of coagulase negative staphylococci (p = 0.017) and Candida spp. (p = 0.003) was observed at time of flap coverage. An ESBL Enterobacteriaceae spp. was found in 5 (12%) patients, associated with fluoroquinolone consumption (OR, 32.4; p = 0.005). Treatment duration was as 20 (IQR, 14–27) weeks, including 11 (IQR, 8–15) after reconstruction. After a follow-up of 54 (IQR, 27–102) weeks, 15 (23%) failures were observed, associated with previous pressure ulcer (OR, 5.7; p = 0.025) and Actinomyces spp. infection (OR, 9.5; p = 0.027). Conclusions Pressure ulcer-related pelvic osteomyelitis is a difficult-to-treat clinical condition, generating an important consumption of broad-spectrum antibiotics. The lack of correlation between outcome and the debridement-to-reconstruction interval argue for a short sequence to limit the total duration of treatment.
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Affiliation(s)
- Johan Andrianasolo
- Department of infectious diseases, Hospices Civils de Lyon, Lyon, France.,CRIOAc Lyon, Regional reference center for the management of complex bone and joint infection, Hospices Civils de Lyon, Lyon, France.,Department of general medicine, Claude Bernard Lyon University, Lyon, France
| | - Tristan Ferry
- Department of infectious diseases, Hospices Civils de Lyon, Lyon, France.,CRIOAc Lyon, Regional reference center for the management of complex bone and joint infection, Hospices Civils de Lyon, Lyon, France.,CIRI - Centre International de Recherche en Infectiologie, Inserm, U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ Lyon, F-69007, Lyon, France
| | - Fabien Boucher
- CRIOAc Lyon, Regional reference center for the management of complex bone and joint infection, Hospices Civils de Lyon, Lyon, France.,Department of plastic, reconstructive and aesthetic surgery, Hospices Civils de Lyon, Lyon, France
| | - Joseph Chateau
- CRIOAc Lyon, Regional reference center for the management of complex bone and joint infection, Hospices Civils de Lyon, Lyon, France.,Department of plastic, reconstructive and aesthetic surgery, Hospices Civils de Lyon, Lyon, France
| | - Hristo Shipkov
- CRIOAc Lyon, Regional reference center for the management of complex bone and joint infection, Hospices Civils de Lyon, Lyon, France.,Department of plastic, reconstructive and aesthetic surgery, Hospices Civils de Lyon, Lyon, France
| | - Fatiha Daoud
- Department of infectious diseases, Hospices Civils de Lyon, Lyon, France.,CRIOAc Lyon, Regional reference center for the management of complex bone and joint infection, Hospices Civils de Lyon, Lyon, France
| | - Evelyne Braun
- Department of infectious diseases, Hospices Civils de Lyon, Lyon, France.,CRIOAc Lyon, Regional reference center for the management of complex bone and joint infection, Hospices Civils de Lyon, Lyon, France
| | - Claire Triffault-Fillit
- Department of infectious diseases, Hospices Civils de Lyon, Lyon, France.,CRIOAc Lyon, Regional reference center for the management of complex bone and joint infection, Hospices Civils de Lyon, Lyon, France
| | - Thomas Perpoint
- Department of infectious diseases, Hospices Civils de Lyon, Lyon, France.,CRIOAc Lyon, Regional reference center for the management of complex bone and joint infection, Hospices Civils de Lyon, Lyon, France
| | - Frédéric Laurent
- CRIOAc Lyon, Regional reference center for the management of complex bone and joint infection, Hospices Civils de Lyon, Lyon, France.,CIRI - Centre International de Recherche en Infectiologie, Inserm, U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ Lyon, F-69007, Lyon, France.,Laboratory of bacteriology, French national reference center for staphylococci, Hospices Civils de Lyon, F-69007, Lyon, France
| | - Alain-Ali Mojallal
- CRIOAc Lyon, Regional reference center for the management of complex bone and joint infection, Hospices Civils de Lyon, Lyon, France.,Department of plastic, reconstructive and aesthetic surgery, Hospices Civils de Lyon, Lyon, France
| | - Christian Chidiac
- Department of infectious diseases, Hospices Civils de Lyon, Lyon, France.,CRIOAc Lyon, Regional reference center for the management of complex bone and joint infection, Hospices Civils de Lyon, Lyon, France.,CIRI - Centre International de Recherche en Infectiologie, Inserm, U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ Lyon, F-69007, Lyon, France
| | - Florent Valour
- Department of infectious diseases, Hospices Civils de Lyon, Lyon, France. .,CRIOAc Lyon, Regional reference center for the management of complex bone and joint infection, Hospices Civils de Lyon, Lyon, France. .,CIRI - Centre International de Recherche en Infectiologie, Inserm, U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ Lyon, F-69007, Lyon, France. .,Service des maladies infectieuses et tropicales, Centre de Référence inter-régional pour la prise en charge des Infections Ostéo-Articulaires complexes (CRIOAc), Hôpital de la Croix-Rousse, 103 Grande-Rue de la Croix-Rousse, 69004, Lyon, France.
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Kaewprag P, Newton C, Vermillion B, Hyun S, Huang K, Machiraju R. Predictive models for pressure ulcers from intensive care unit electronic health records using Bayesian networks. BMC Med Inform Decis Mak 2017; 17:65. [PMID: 28699545 PMCID: PMC5506589 DOI: 10.1186/s12911-017-0471-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background We develop predictive models enabling clinicians to better understand and explore patient clinical data along with risk factors for pressure ulcers in intensive care unit patients from electronic health record data. Identifying accurate risk factors of pressure ulcers is essential to determining appropriate prevention strategies; in this work we examine medication, diagnosis, and traditional Braden pressure ulcer assessment scale measurements as patient features. In order to predict pressure ulcer incidence and better understand the structure of related risk factors, we construct Bayesian networks from patient features. Bayesian network nodes (features) and edges (conditional dependencies) are simplified with statistical network techniques. Upon reviewing a network visualization of our model, our clinician collaborators were able to identify strong relationships between risk factors widely recognized as associated with pressure ulcers. Methods We present a three-stage framework for predictive analysis of patient clinical data: 1) Developing electronic health record feature extraction functions with assistance of clinicians, 2) simplifying features, and 3) building Bayesian network predictive models. We evaluate all combinations of Bayesian network models from different search algorithms, scoring functions, prior structure initializations, and sets of features. Results From the EHRs of 7,717 ICU patients, we construct Bayesian network predictive models from 86 medication, diagnosis, and Braden scale features. Our model not only identifies known and suspected high PU risk factors, but also substantially increases sensitivity of the prediction - nearly three times higher comparing to logistical regression models - without sacrificing the overall accuracy. We visualize a representative model with which our clinician collaborators identify strong relationships between risk factors widely recognized as associated with pressure ulcers. Conclusions Given the strong adverse effect of pressure ulcers on patients and the high cost for treating pressure ulcers, our Bayesian network based model provides a novel framework for significantly improving the sensitivity of the prediction model. Thus, when the model is deployed in a clinical setting, the caregivers can suitably respond to conditions likely associated with pressure ulcer incidence.
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Affiliation(s)
- Pacharmon Kaewprag
- Department of Computer Science and Engineering, The Ohio State University, Columbus, Ohio, USA.
| | - Cheryl Newton
- Department of Critical Care Nursing, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Brenda Vermillion
- College of Nursing, The Ohio State University, Columbus, Ohio, USA.,Department of Health Services Nursing Education, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sookyung Hyun
- College of Nursing, Pusan National University, Busan, South Korea
| | - Kun Huang
- Department of Computer Science and Engineering, The Ohio State University, Columbus, Ohio, USA. .,Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio, USA.
| | - Raghu Machiraju
- Department of Computer Science and Engineering, The Ohio State University, Columbus, Ohio, USA. .,Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio, USA.
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Schivo M, Aksenov AA, Pasamontes A, Cumeras R, Weisker S, Oberbauer AM, Davis CE. A rabbit model for assessment of volatile metabolite changes observed from skin: a pressure ulcer case study. J Breath Res 2017; 11:016007. [PMID: 28068292 DOI: 10.1088/1752-7163/aa51d7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Human skin presents a large, easily accessible matrix that is potentially useful for diagnostic applications based on whole body metabolite changes-some of which will be volatile and detected using minimally invasive tools. Unfortunately, identifying skin biomarkers that can be reliably linked to a particular condition is challenging due to a large variability of genetics, dietary intake, and environmental exposures within human populations. This leads to a paucity of clinically validated volatile skin biomarker compounds. Animal models present a very convenient and attractive way to circumvent many of the variability issues. The rabbit (Leporidae) is a potentially logistically useful model to study the skin metabolome, but very limited knowledge of its skin metabolites exists. Here we present the first comprehensive assessment of the volatile fraction of rabbit skin metabolites using polydimethylsiloxane sorbent patch sampling in conjunction with gas chromatography/mass spectrometry. A collection of compounds that are secreted from rabbit skin was documented, and predominantly acyclic long-chain alkyls and alcohols were detected. We then utilized this animal model to study differences between intact skin and skin with early pressure ulcers, as the latter are a major problem in intensive care units. Four New Zealand female white rabbits underwent ulcer formation on one ear with the other ear as a control. Early-stage ulcers were created with neodymium magnets. Histologic analysis showed acute heterophilic dermatitis, edema, and micro-hemorrhage on the ulcerated ears with normal findings on the control ears. The metabolomic analysis revealed subtle but noticeable differences, with several compounds associated with the oxidative stress-related degradation of lipids found to be present in greater abundances in ulcerated ears. The metabolomic findings correlate with histologic evidence of early-stage ulcers. We postulate that the Leporidae model recapitulated the vascular changes associated with ulcer formation. This study illustrates the potential usefulness of the Leporidae model for skin metabolome studies. Additionally, skin metabolome analysis may enhance an understanding of non-skin sources such as urine or breath.
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Affiliation(s)
- Michael Schivo
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of California, Davis, Sacramento, CA 95617, USA. Center for Comparative Respiratory Biology and Medicine, University of California, Davis, Davis, CA 95616, USA
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