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Uçkay I, Bomberg H, Risch M, Müller D, Betz M, Farshad M. Broad-spectrum antibiotic prophylaxis in tumor and infected orthopedic surgery-the prospective-randomized, microbiologist-blinded, stratified, superiority trials: BAPTIST Trials. Trials 2024; 25:69. [PMID: 38243311 PMCID: PMC10799415 DOI: 10.1186/s13063-023-07605-5] [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: 10/27/2022] [Accepted: 08/26/2023] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND The perioperative antibiotic prophylaxis with 1st or 2nd generation cephalosporins is evidence-based in orthopedic surgery. There are, however, situations with a high risk of prophylaxis-resistant surgical site infections (SSI). METHODS We perform a superiority randomized controlled trial with a 10% margin and a power of 90% in favor of the broad-spectrum prophylaxis. We will randomize orthopedic interventions with a high risk for SSI due to selection of resistant pathogens (open fractures, surgery under therapeutic antibiotics, orthopedic tumor surgery, spine surgery with American Society of Anesthesiologists (ASA) score ≥ 3 points) in a prospective-alternating scheme (1:1, standard prophylaxis with cefuroxime versus a broad-spectrum prophylaxis of a combined single-shot of vancomycin 1 g and gentamicin 5 mg/kg parenterally). The primary outcome is "remission" at 6 weeks for most orthopedic surgeries or at 1 year for surgeries with implant. Secondary outcomes are the risk for prophylaxis-resistant SSI pathogens, revision surgery for any reason, change of antibiotic therapy during the treatment of infection, adverse events, and the postoperative healthcare-associated infections other than SSI within 6 weeks (e.g., urine infections or pneumonia). With event-free surgeries to 95% in the broad-spectrum versus 85% in the standard prophylaxis arm, we need 2 × 207 orthopedic surgeries. DISCUSSION In selected patients with a high risk for infections due to selection of prophylaxis-resistant SSI, a broad-spectrum combination with vancomycin and gentamycin might prevent SSIs (and other postoperative infections) better than the prophylaxis with cefuroxime. TRIAL REGISTRATION ClinicalTrial.gov NCT05502380. Registered on 12 August 2022. Protocol version: 2 (3 June 2022).
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Affiliation(s)
- Ilker Uçkay
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
- Unit for Clinical and Applied Research, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
- Infection Control, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Hagen Bomberg
- Department of Anesthesiology, Intensive Care and Pain Medicine, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Markus Risch
- Department of Anesthesiology, Intensive Care and Pain Medicine, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Daniel Müller
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Michael Betz
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Mazda Farshad
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
- Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
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Rane A, Ghulam QM, Hannan ZD, McKegg PC, Fisher K, Joshi M, O'Hara NN, O'Toole RV. Predicting Which Species of Bacteria Will Cause an Infection After Fracture Surgery. Orthopedics 2024; 47:e19-e25. [PMID: 37216565 DOI: 10.3928/01477447-20230517-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
The aim of this study was to develop and validate risk prediction models for deep surgical site infection (SSI) caused by specific bacterial pathogens after fracture fixation. A retrospective case-control study was conducted at a level I trauma center. Fifteen candidate predictors of the bacterial pathogens in deep SSI were evaluated to develop models of bacterial risk. The study included 441 patients with orthopedic trauma with deep SSI after fracture fixation and 576 control patients. The main outcome measurement was deep SSI cultures positive for methicillin-sensitive Staphylococcus aureus (MSSA), methicillin-resistant S aureus (MRSA), gram-negative rods (GNRs), anaerobes, or polymicrobial infection within 1 year of injury. Prognostic models were developed for five bacterial pathogen outcomes. Mean area under the curve ranged from 0.70 (GNRs) to 0.74 (polymicrobial). Strong predictors of MRSA were American Society of Anesthesiologists (ASA) classification of III or greater (odds ratio [OR], 3.4; 95% CI, 1.6-8.0) and time to fixation greater than 7 days (OR, 3.4; 95% CI, 1.9-5.9). Gustilo type III fracture was the strongest predictor of MSSA (OR, 2.5; 95% CI, 1.6-3.9) and GNRs (OR, 3.4; 95% CI, 2.3-5.0). ASA classification of III or greater was the strongest predictor of polymicrobial infection (OR, 5.9; 95% CI, 2.7-15.5) and was associated with increased odds of GNRs (OR, 2.7; 95% CI, 1.5-5.5). Our models predict the risk of MRSA, MSSA, GNR, anaerobe, and polymicrobial infections in patients with fractures. The models might allow for modification of preoperative antibiotic selection based on the particular pathogen posing greatest risk for this patient population. [Orthopedics. 2024;47(1):e19-e25.].
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Ansorge A, Betz M, Wetzel O, Burkhard MD, Dichovski I, Farshad M, Uçkay I. Perioperative Urinary Catheter Use and Association to (Gram-Negative) Surgical Site Infection after Spine Surgery. Infect Dis Rep 2023; 15:717-725. [PMID: 37987402 PMCID: PMC10660755 DOI: 10.3390/idr15060064] [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: 08/28/2023] [Revised: 11/07/2023] [Accepted: 11/08/2023] [Indexed: 11/22/2023] Open
Abstract
This study evaluates potential associations between the perioperative urinary catheter (UC) carriage and (Gram-negative) surgical site infections (SSIs) after spine surgery. It is a retrospective, single-center, case-control study stratifying group comparisons, case-mix adjustments using multivariate logistic regression analyses. Around half of the patients (2734/5485 surgeries) carried a UC for 1 day (median duration) (interquartile range, 1-1 days). Patients with perioperative UC carriage were compared to those without regarding SSI, in general, and Gram-negative, exclusively. The SSI rate was 1.2% (67/5485), yielding 67 revision surgeries. Gram-negative pathogens caused 16 SSIs. Seven Gram-negative episodes revealed the same pathogen concomitantly in the urine and the spine. In the multivariate analysis, the UC carriage duration was associated with SSI (OR 1.1, 95% confidence interval 1.1-1.1), albeit less than classical risk factors like diabetes (OR 2.2, 95%CI 1.1-4.2), smoking (OR 2.4, 95%CI 1.4-4.3), or higher ASA-Scores (OR 2.3, 95%CI 1.4-3.6). In the second multivariate analysis targeting Gram-negative SSIs, the female sex (OR 3.8, 95%CI 1.4-10.6) and a UC carriage > 1 day (OR 5.5, 95%CI 1.5-20.3) were associated with Gram-negative SSIs. Gram-negative SSIs after spine surgery seem associated with perioperative UC carriage, especially in women. Other SSI risk factors are diabetes, smoking, and higher ASA scores.
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Affiliation(s)
- Alexandre Ansorge
- University Spine Centre Zürich, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Michael Betz
- University Spine Centre Zürich, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Oliver Wetzel
- University Spine Centre Zürich, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Marco Dimitri Burkhard
- University Spine Centre Zürich, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Igor Dichovski
- University Spine Centre Zürich, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Mazda Farshad
- University Spine Centre Zürich, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Ilker Uçkay
- Unit for Clinical and Applied Research, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
- Infectiology and Infection Control, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
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Li Y, Zhang X, Ji B, Wulamu W, Yushan N, Guo X, Cao L. One-stage revision using intra-articular carbapenem infusion effectively treats chronic periprosthetic joint infection caused by Gram-negative organisms. Bone Joint J 2023; 105-B:284-293. [PMID: 36854321 DOI: 10.1302/0301-620x.105b3.bjj-2022-0926.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
Gram-negative periprosthetic joint infection (PJI) has been poorly studied despite its rapidly increasing incidence. Treatment with one-stage revision using intra-articular (IA) infusion of antibiotics may offer a reasonable alternative with a distinct advantage of providing a means of delivering the drug in high concentrations. Carbapenems are regarded as the last line of defense against severe Gram-negative or polymicrobial infection. This study presents the results of one-stage revision using intra-articular carbapenem infusion for treating Gram-negative PJI, and analyzes the characteristics of bacteria distribution and drug sensitivity. We retrospectively reviewed 32 patients (22 hips and 11 knees) who underwent single-stage revision combined with IA carbapenem infusion between November 2013 and March 2020. The IA and intravenous (IV) carbapenem infusions were administered for a single Gram-negative infection, and IV vancomycin combined with IA carbapenems and vancomycin was applied for polymicrobial infection including Gram-negative bacteria. The bacterial community distribution, drug sensitivity, infection control rate, functional recovery, and complications were evaluated. Reinfection or death caused by PJI was regarded as a treatment failure. Gram-negative PJI was mainly caused by Escherichia coli (8/34), Enterobacter cloacae (7/34), and Klebsiella pneumoniae (5/34). Seven cases (7/32) involved polymicrobial PJIs. The resistance rates of penicillin, cephalosporin, quinolones, and sulfonamides were > 10%, and all penicillin and partial cephalosporins (first and second generation) were > 30%. Of 32 cases, treatment failed to eradicate infection in only three cases (9.4%), at a mean follow-up of 55.1 months (SD 25 to 90). The mean postoperative Harris Hip Score and Hospital for Special Surgery knee score at the most recent follow-up were 81 (62 to 91) and 79 (56 to 89), respectively. One patient developed a fistula, and another presented with a local rash on an infected joint. The use of IA carbapenem delivered alongside one-stage revision effectively controlled Gram-negative infection and obtained acceptable clinical outcomes with few complications. Notably, first- and second-generation cephalosporins and penicillin should be administrated with caution, due to a high incidence of resistance.
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Affiliation(s)
- Yicheng Li
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
| | - Xiaogang Zhang
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
| | - Baochao Ji
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
| | - Wuhuzi Wulamu
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
| | - Nuerailijiang Yushan
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
| | - Xiaobin Guo
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
| | - Li Cao
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
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Risk Factors for Surgical Site Infections in Elective Orthopedic Foot and Ankle Surgery: The Role of Diabetes Mellitus. J Clin Med 2023; 12:jcm12041608. [PMID: 36836144 PMCID: PMC9963651 DOI: 10.3390/jcm12041608] [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: 01/16/2023] [Revised: 02/12/2023] [Accepted: 02/13/2023] [Indexed: 02/19/2023] Open
Abstract
Surgical site infection (SSI) after elective orthopedic foot and ankle surgery is uncommon and may be higher in selected patient groups. Our main aim was to investigate the risk factors for SSI in elective orthopedic foot surgery and the microbiological results of SSI in diabetic and non-diabetic patients, in a tertiary foot center between 2014 and 2022. Overall, 6138 elective surgeries were performed with an SSI risk of 1.88%. The main independent associations with SSI in a multivariate logistic regression analysis were an ASA score of 3-4 points, odds ratio (OR) 1.87 (95% confidence interval (CI) 1.20-2.90), internal, OR 2.33 (95% CI 1.56-3.49), and external material, OR 3.08 (95% CI 1.56-6.07), and more than two previous surgeries, OR 2.86 (95% CI 1.93-4.22). Diabetes mellitus showed an increased risk in the univariate analysis, OR 3.94 (95% CI 2.59-5.99), and in the group comparisons (three-fold risk). In the subgroup of diabetic foot patients, a pre-existing diabetic foot ulcer increased the risk for SSI, OR 2.99 (95% CI 1.21-7.41), compared to non-ulcered diabetic patients. In general, gram-positive cocci were the predominant pathogens in SSI. In contrast, polymicrobial infections with gram-negative bacilli were more common in contaminated foot surgeries. In the latter group, the perioperative antibiotic prophylaxis by second-generation cephalosporins did not cover 31% of future SSI pathogens. Additionally, selected groups of patients revealed differences in the microbiology of the SSI. Prospective studies are required to determine the importance of these findings for optimal perioperative antibiotic prophylactic measures.
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Ibrahim MM, Liu Y, Ure K, Hall CW, Mah TF, Abdelbary H. Establishment of a Novel Rat Model of Gram-Negative Periprosthetic Joint Infection Using Cementless Hip Hemiarthroplasty. J Bone Joint Surg Am 2023; 105:42-52. [PMID: 36598474 DOI: 10.2106/jbjs.22.00094] [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] [Indexed: 01/05/2023]
Abstract
BACKGROUND Gram-negative periprosthetic joint infections (GN-PJIs) present unique challenges. Our aim was to establish a clinically representative GN-PJI model that recapitulates biofilm formation in vivo. We also hypothesized that biofilm formation on the implant surface would affect its ability to osseointegrate. METHODS Three-dimensionally-printed medical-grade titanium hip implants were used to replace the femoral heads of male Sprague-Dawley rats. GN-PJI was induced using 2 bioluminescent Pseudomonas aeruginosa strains: a reference strain (PA14-lux) and a mutant biofilm-defective strain (ΔflgK-lux). Infection was monitored in real time using an in vivo imaging system (IVIS) and magnetic resonance imaging (MRI). Bacterial loads were quantified utilizing the viable colony count. Biofilm formation at the bone-implant interface was visualized using field-emission scanning electron microscopy (FE-SEM). Implant stability, as an outcome, was directly assessed by quantifying osseointegration using microcomputed tomography, and indirectly assessed by identifying gait-pattern changes. RESULTS Bioluminescence detected by the IVIS was focused on the hip region and demonstrated localized infection, with greater ability of PA14-lux to persist in the model compared with the ΔflgK-lux strain, which is defective in biofilm formation. This was corroborated by MRI, as PA14-lux induced relatively larger implant-related abscesses. Biofilm formation at the bone-implant interface induced by PA14-lux was visualized using FE-SEM versus defective-biofilm formation by ΔflgK-lux. Quantitatively, the average viable colony count of the sonicated implants, in colony-forming units/mL, was 3.77 × 108 for PA14-lux versus 3.65 × 103 for ΔflgK-lux, with a 95% confidence interval around the difference of 1.45 × 108 to 6.08 × 108 (p = 0.0025). This difference in the ability to persist in the model was reflected significantly on implant osseointegration, with a mean intersection surface of 4.1 × 106 ± 1.99 × 106 μm2 for PA14-lux versus 6.44 × 106 ± 2.53 × 106 μm2 for ΔflgK-lux and 7.08 × 106 ± 1.55 × 106 μm2 for the noninfected control (p = 0.048). CONCLUSIONS To our knowledge, this proposed, novel in vivo biofilm-based model is the most clinically representative for GN-PJI to date, since animals can bear weight on the implant, poor osseointegration was associated with biofilm formation, and localized PJI was assessed by various modalities. CLINICAL RELEVANCE This model will allow for more reliable testing of novel biofilm-targeting therapeutics.
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Affiliation(s)
- Mazen M Ibrahim
- Department of Biochemistry, Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,The Ottawa Hospital, Ottawa, Ontario, Canada.,Department of Orthopaedic Surgery, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Yun Liu
- Materials Characterization Core Facility, Centre for Advanced Materials Research (CAMaR), University of Ottawa, Ottawa, Ontario, Canada
| | - Kerstin Ure
- Animal Behavior and Physiology Core, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Clayton W Hall
- Department of Biochemistry, Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Division of Medical Microbiology, Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Thien-Fah Mah
- Department of Biochemistry, Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Hesham Abdelbary
- Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,The Ottawa Hospital, Ottawa, Ontario, Canada
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Giannitsioti E, Salles M, Mavrogenis A, Rodriguez-Pardo D, Los-Arcos I, Ribera A, Ariza J, del Toro M, Nguyen S, Senneville E, Bonnet E, Chan M, Pasticci M, Petersdorf S, Benito N, O' Connell N, Blanco García A, Skaliczki G, Tattevin P, Kocak Tufan Z, Pantazis N, Megaloikonomos P, Papagelopoulos P, Soriano A, Papadopoulos A, the ESGIAI collaborators study group. Osteosynthesis-associated infection of the lower limbs by multidrug-resistant and extensively drug-resistant Gram-negative bacteria: a multicentre cohort study. J Bone Jt Infect 2022; 7:279-288. [PMID: 36644590 PMCID: PMC9832304 DOI: 10.5194/jbji-7-279-2022] [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: 05/17/2022] [Accepted: 11/19/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose: The purpose of this study was the clinical and therapeutic assessment of lower-limb osteosynthesis-associated infection (OAI) by multidrug-resistant (MDR) and extensively drug-resistant (XDR) Gram-negative bacteria (GNB), which have been poorly studied to date. Methods: A prospective multicentre observational study was conducted on behalf of ESGIAI (the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group on Implant-Associated Infections). Factors associated with remission of the infection were evaluated by multivariate and Cox regression analysis for a 24-month follow-up period. Results: Patients ( n = 57 ) had a history of trauma (87.7 %), tumour resection (7 %) and other bone lesions (5.3 %). Pathogens included Escherichia coli ( n = 16 ), Pseudomonas aeruginosa ( n = 14 ; XDR 50 %), Klebsiella spp. ( n = 7 ), Enterobacter spp. ( n = 9 ), Acinetobacter spp. ( n = 5 ), Proteus mirabilis ( n = 3 ), Serratia marcescens ( n = 2 ) and Stenotrophomonas maltophilia ( n = 1 ). The prevalence of ESBL (extended-spectrum β -lactamase), fluoroquinolone and carbapenem resistance were 71.9 %, 59.6 % and 17.5 % respectively. Most patients ( n = 37 ; 64.9 %) were treated with a combination including carbapenems ( n = 32 ) and colistin ( n = 11 ) for a mean of 63.3 d. Implant retention with debridement occurred in early OAI (66.7 %), whereas the infected device was removed in late OAI (70.4 %) ( p = 0.008 ). OAI remission was achieved in 29 cases (50.9 %). The type of surgery, antimicrobial resistance and duration of treatment did not significantly influence the outcome. Independent predictors of the failure to eradicate OAI were age > 60 years (hazard ratio, HR, of 3.875; 95 % confidence interval, CI95 %, of 1.540-9.752; p = 0.004 ) and multiple surgeries for OAI (HR of 2.822; CI95 % of 1.144-6.963; p = 0.024 ). Conclusions: Only half of the MDR/XDR GNB OAI cases treated by antimicrobials and surgery had a successful outcome. Advanced age and multiple surgeries hampered the eradication of OAI. Optimal therapeutic options remain a challenge.
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Affiliation(s)
- Efthymia Giannitsioti
- Fourth Department of Internal Medicine, University General Hospital Attikon, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Mauro José Salles
- Division of Infectious Diseases, Department of Internal Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Andreas Mavrogenis
- First Department of Orthopaedics, University General Hospital Attikon, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Dolors Rodriguez-Pardo
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Ibai Los-Arcos
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Alba Ribera
- Department of Infectious Diseases, Hospital Universitari Bellvitge, Barcelona, Spain
| | - Javier Ariza
- Department of Infectious Diseases, Hospital Universitari Bellvitge, Barcelona, Spain
| | - María Dolores del Toro
- Infectious Diseases Unit, Hospital Universitario Virgen Macarena, Instituto de Biomedicina de Sevilla (IBIS), Universidad de Sevilla, Seville, Spain
| | - Sophie Nguyen
- Infectious Diseases Department, Gustave Dron Hospital, Tourcoing, France
| | - Eric Senneville
- Infectious Diseases Department, Gustave Dron Hospital, Tourcoing, France
| | - Eric Bonnet
- Department of Infectious Diseases, Clinique Pasteur, Toulouse, France
| | - Monica Chan
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Sabine Petersdorf
- Institute for Medical Laboratory Diagnostics, Helios University Clinic Wuppertal, Wuppertal, Germany
| | - Natividad Benito
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Nuala O' Connell
- Department of Clinical Microbiology, University Hospital Limerick, Limerick, Ireland
| | - Antonio Blanco García
- Bone and Joint Infection Unit, Department of Emergency Medicine, IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain
| | - Gábor Skaliczki
- Department of Orthopaedics, Semmelweis University, Budapest, Hungary
| | - Pierre Tattevin
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - Zeliha Kocak Tufan
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Yildirim Beyazit University, Ankara Atatürk Education and Research Hospital, Ankara, Turkey
| | - Nikolaos Pantazis
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Panayiotis D. Megaloikonomos
- First Department of Orthopaedics, University General Hospital Attikon, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Panayiotis Papagelopoulos
- First Department of Orthopaedics, University General Hospital Attikon, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Alejandro Soriano
- Department of Infectious Diseases, Hospital Clínic, Barcelona, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Antonios Papadopoulos
- Fourth Department of Internal Medicine, University General Hospital Attikon, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Uçkay I, Lebowitz D, Kressmann B, von Dach E, Lipsky BA, Gariani K. Pseudomonal Diabetic Foot Infections: Vive la Différence? Mayo Clin Proc Innov Qual Outcomes 2022; 6:250-256. [PMID: 35634135 PMCID: PMC9130228 DOI: 10.1016/j.mayocpiqo.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Objective To assess the outcomes of diabetic foot infections (DFIs) due to Pseudomonas aeruginosa. Patients and Methods From April 24, 2013 to July 31, 2016, we analyzed data from patients prospectively enrolled in our clinical pathway of DFIs, comparing those with infection due to Pseudomonas with those without infection due to Pseudomonas. Results Overall, we assessed 1018 cases of DFIs: 392 with osteomyelitis and 626 with only soft tissue infections. The prevalence of P aeruginosa in deep wound cultures was 10% (104/1018); of the 1018 cultures, 22 were monomicrobial, 82 were polymicrobial, and 46 were with osteomyelitis. Overall, the patients were treated with a median of 1 surgical debridement and a total of 20 days of antibiotic therapy. In a comparison of crude groups, the proportion of clinical failures was significantly higher with Pseudomonas than with other pathogens (36/104 [35%] vs 218/914 [24%], respectively; P=.02). A multivariate analysis showed that pseudomonal DFIs did not recur more often than nonpseudomonal DFIs (hazard ratio, 1.0; 95% confidence interval, 0.6-1.7). Among the 104 cases of pseudomonal DFIs, there was no association between failure of treatment and the total duration of antibiotic therapy, duration of intravenous therapy, duration of combined antibiotic therapy with more than 1 agent, or duration of oral (fluoroquinolone) therapy. Among 15 cases of pseudomonal recurrence, 2 (13%) developed resistance to the antibiotic agent used for the index episode. Conclusion For DFIs caused by P aeruginosa, other than choosing an antibiotic agent that is active against the organism, it does not appear necessary to treat with a different therapeutic regimen compared with the treatment of nonpseudomonal DFIs. There is no difference!
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Affiliation(s)
- Ilker Uçkay
- Clinical Pathway for Diabetic Foot Infections, Geneva University Hospitals, Geneva, Switzerland
- Infection Control Program, Geneva University Hospitals, Geneva, Switzerland
- Infectiology, Balgrist University Hospital, Zurich, Switzerland
- Correspondence: Address to Ilker Uçkay, MD, Balgrist University Hospital, Forchstrasse 340, 8008 Zurich, Switzerland.
| | - Dan Lebowitz
- Infection Control Program, Geneva University Hospitals, Geneva, Switzerland
| | - Benjamin Kressmann
- Clinical Pathway for Diabetic Foot Infections, Geneva University Hospitals, Geneva, Switzerland
| | - Elodie von Dach
- Infection Control Program, Geneva University Hospitals, Geneva, Switzerland
| | - Benjamin A. Lipsky
- Clinical Pathway for Diabetic Foot Infections, Geneva University Hospitals, Geneva, Switzerland
- Department of Medicine, University of Washington, Seattle, WA
| | - Karim Gariani
- Clinical Pathway for Diabetic Foot Infections, Geneva University Hospitals, Geneva, Switzerland
- Division of Endocrinology, Diabetes, Nutrition and Therapeutic Patient Education, Geneva University Hospitals, Geneva, Switzerland
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Islam MS, Islam SS, Parvin S, Manjur M, Islam MR, Halder RC, Islam MS, Rahaman SK, Hoque M, Faruque MO, Haque AKMN. Current pathogens infecting open fracture tibia and their antibiotic susceptibility at a tertiary care teaching hospital in South East Asia. Infect Prev Pract 2022; 4:100205. [PMID: 35243317 PMCID: PMC8857645 DOI: 10.1016/j.infpip.2022.100205] [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: 08/19/2021] [Accepted: 01/27/2022] [Indexed: 10/30/2022] Open
Abstract
Background Methods Results Conclusion
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10
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Functionalization of Synthetic Bone Substitutes. Int J Mol Sci 2021; 22:ijms22094412. [PMID: 33922517 PMCID: PMC8122961 DOI: 10.3390/ijms22094412] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 04/19/2021] [Accepted: 04/20/2021] [Indexed: 12/11/2022] Open
Abstract
Bone substitutes have been applied to treat osseous defects for a long time. To prevent implant related infection (IRI) and enhance bone healing functionalized biomaterials, antibiotics and osteoinductive substances have been introduced. This study gives an overview of the current available surface-coated bone substitutes and provides an outlook for future perspectives.
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Lipsky BA, Uçkay İ. Treating Diabetic Foot Osteomyelitis: A Practical State-of-the-Art Update. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:339. [PMID: 33916055 PMCID: PMC8066570 DOI: 10.3390/medicina57040339] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 12/17/2022]
Abstract
Background and Objectives: Diabetic foot osteomyelitis (DFO) can be difficult to treat and securing optimal clinical outcomes requires a multidisciplinary approach involving a wide variety of medical, surgical and other health care professionals, as well as the patient. Results of studies conducted in the past few years have allowed experts to formulate guidelines that can improve clinical outcomes. Material and Methods: We conducted a narrative review of the literature on treat- ment of DFO, with an emphasis on studies published in the last two years, especially regarding antimicrobial therapies and surgical approached to treatment of DFO, supplemented by our own extensive clinical and research experience in this field. Results: Major amputations were once com- mon for DFO but, with improved diagnostic and surgical techniques, "conservative" surgery (foot- sparing, resecting only the infected and necrotic bone) is becoming commonplace, especially for forefoot infections. Traditional antibiotic therapy, which has been administered predominantly in- travenously and frequently for several months, can often be replaced by appropriately selected oral antibiotic regimens following only a brief (or even no) parenteral therapy, and given for no more than 6 weeks. Based on ongoing studies, the recommended duration of treatment may soon be even shorter, especially for cases in which a substantial portion of the infected bone has been resected. Using the results of cultures (preferably of bone specimens) and antimicrobial stewardship princi- ples allows clinicians to select evidence-based antibiotic regimens, often of a limited pathogen spec- trum. Intra-osseous antimicrobial and surgical approaches to treatment are also evolving in light of ongoing research. Conclusions: In this narrative, evidenced-based review, taking consideration of principles of antimicrobial stewardship and good surgical practice, we have highlighted the recent literature and offered practical, state-of-the-art advice on the antibiotic and surgical management of DFO.
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Affiliation(s)
- Benjamin A. Lipsky
- Department of Medicine, University of Washington, Seattle, WA 98116, USA
| | - İlker Uçkay
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland;
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Uçkay I, Holy D, Schöni M, Waibel FWA, Trache T, Burkhard J, Böni T, Lipsky BA, Berli MC. How good are clinicians in predicting the presence of Pseudomonas spp. in diabetic foot infections? A prospective clinical evaluation. Endocrinol Diabetes Metab 2021; 4:e00225. [PMID: 33855224 PMCID: PMC8029573 DOI: 10.1002/edm2.225] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/22/2020] [Accepted: 12/26/2020] [Indexed: 12/17/2022] Open
Abstract
Introduction The most frequently prescribed empirical antibiotic agents for mild and moderate diabetic foot infections (DFIs) are amino-penicillins and second-generation cephalosporins that do not cover Pseudomonas spp. Many clinicians believe they can predict the involvement of Pseudomonas in a DFI by visual and/or olfactory clues, but no data support this assertion. Methods In this prospective observational study, we separately asked 13 experienced (median 11 years) healthcare workers whether they thought the Pseudomonas spp. would be implicated in the DFI. Their predictions were compared with the results of cultures of deep/intraoperative specimens and/or the clinical remission of DFI achieved with antibiotic agents that did not cover Pseudomonas. Results Among 221 DFI episodes in 88 individual patients, intraoperative tissue cultures grew Pseudomonas in 22 cases (10%, including six bone samples). The presence of Pseudomonas was correctly predicted with a sensitivity of 0.32, specificity of 0.84, positive predictive value of 0.18 and negative predictive value 0.92. Despite two feedbacks of the interim results and a 2-year period, the clinicians' predictive performance did not improve. Conclusion The combined visual and olfactory performance of experienced clinicians in predicting the presence of Pseudomonas in a DFI was moderate, with better specificity than sensitivity, and did not improve over time. Further investigations are needed to determine whether clinicians should use a negative prediction of the presence of Pseudomonas in a DFI, especially in settings with a high prevalence of pseudomonal DFIs.
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Affiliation(s)
- Ilker Uçkay
- InfectiologyBalgrist University HospitalZurichSwitzerland
- Department of Orthopedic SurgeryBalgrist University HospitalZurichSwitzerland
| | - Dominique Holy
- Internal MedicineBalgrist University HospitalZurichSwitzerland
| | - Madlaina Schöni
- Department of Orthopedic SurgeryBalgrist University HospitalZurichSwitzerland
| | - Felix W. A. Waibel
- Department of Orthopedic SurgeryBalgrist University HospitalZurichSwitzerland
| | - Tudor Trache
- Department of Orthopedic SurgeryBalgrist University HospitalZurichSwitzerland
| | - Jan Burkhard
- Internal MedicineBalgrist University HospitalZurichSwitzerland
| | - Thomas Böni
- Department of Orthopedic SurgeryBalgrist University HospitalZurichSwitzerland
| | | | - Martin C. Berli
- Department of Orthopedic SurgeryBalgrist University HospitalZurichSwitzerland
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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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Benkabouche M, Racloz G, Spechbach H, Lipsky BA, Gaspoz JM, Uçkay I. Four versus six weeks of antibiotic therapy for osteoarticular infections after implant removal: a randomized trial. J Antimicrob Chemother 2020; 74:2394-2399. [PMID: 31106353 DOI: 10.1093/jac/dkz202] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 03/26/2019] [Accepted: 04/08/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The optimal duration of antibiotic therapy for treating orthopaedic implant infections after surgical drainage and complete implant removal is unknown. METHODS This was a single-centre, unblinded, prospective trial randomizing (1:1) eligible patients to either 4 or 6 weeks of systemic, pathogen-targeted antibiotic therapy. Clinical trial registration number: ClinicalTrials.gov (NCT0362209). RESULTS We analysed 123 eligible patients (62 in the 4 week antibiotic arm and 61 in the 6 week arm) in the ITT analysis. The patients' median age was 64 years, 75 (61%) were men and 38 (31%) were immunocompromised. The most common types of infection treated included: two-stage exchange procedure for prosthetic joint infection (n = 38); orthopaedic plate infection (44) and infected nail implants (11). The median duration of post-explant intravenous antibiotic therapy was 4 days. Overall, 120 episodes (98%) were cured microbiologically and 116 (94%) clinically after a median follow-up period of 2.2 years. During follow-up, four patients had a clinical recurrence with a pathogen other than the initial causative agent. We noted recurrence of clinical infection in four patients in the 4 week arm and three patients in the 6 week arm (4/62 versus 3/61; χ2 test; P = 0.74); in all cases, this occurred at around 2 months following the end of antibiotic treatment. CONCLUSIONS We found no statistically significant difference in the rates of clinical or microbiological remission between patients randomized to only 4 compared with 6 weeks of systemic antibiotic therapy after removal of an infected osteoarticular implant.
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Affiliation(s)
- Mohamed Benkabouche
- Department of Community Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Guillaume Racloz
- Orthopaedic Surgery Service, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.,Orthopaedic Service of Surgery, Pourtales Hospital, Neuchâtel, Switzerland
| | - Hervé Spechbach
- Department of Community Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Benjamin A Lipsky
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Jean-Michel Gaspoz
- Department of Community Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Ilker Uçkay
- Orthopaedic Surgery Service, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.,Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.,Infectiology, Balgrist University Hospital and Faculty of Medicine, Zurich, Switzerland
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Bacterial Profile, Multi-Drug Resistance and Seasonality Following Lower Limb Orthopaedic Surgery in Tropical and Subtropical Australian Hospitals: An Epidemiological Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17020657. [PMID: 31968529 PMCID: PMC7013644 DOI: 10.3390/ijerph17020657] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 01/12/2020] [Accepted: 01/15/2020] [Indexed: 12/11/2022]
Abstract
We aimed to describe the epidemiology, multi-drug resistance and seasonal distribution of bacteria cultured within 12 months following lower limb orthopaedic surgery in tropical and subtropical Australian hospitals between 2010 and 2017. We collected data from four tropical and two subtropical hospitals. Categorical variables were examined using the Pearson Chi-squared test or Fisher's Exact test, and continuous variables with the Student t-test or Mann-Whitney U test. A Poisson regression model was used to examine the relationship between season, weather and the incidence of Staphylococcus and nonfermentative species. We found that at tropical sites, nonfermenters (Pseudomonas aeruginosa and Acinetobacter baumannii) were more common (28.7% vs. 21.6%, p = 0.018), and patients were more likely to culture multi-drug-resistant (MDR) nonfermenters (11.4% vs. 1.3%, p = 0.009) and MDR Staphylococcus aureus (35.9% vs. 24.6%, p = 0.006). At tropical sites, patients were more likely to be younger (65.9 years vs. 72.0, p = < 0.001), male (57.7% vs. 47.8%, p = 0.005), having knee surgery (45.3% vs. 34.5%, p = 0.002) and undergoing primary procedures (85.0% vs. 73.0%, p = < 0.001). Species were similar between seasons in both tropical and subtropical hospitals. Overall, we found that following lower limb orthopaedic surgery in tropical compared with subtropical Australia, patients were more likely to culture nonfermenters and some MDR species.
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16
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Rossel A, Lebowitz D, Gariani K, Abbas M, Kressmann B, Assal M, Tscholl P, Stafylakis D, Uçkay I. Stopping antibiotics after surgical amputation in diabetic foot and ankle infections-A daily practice cohort. Endocrinol Diabetes Metab 2019; 2:e00059. [PMID: 31008367 PMCID: PMC6458464 DOI: 10.1002/edm2.59] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 12/28/2018] [Accepted: 12/30/2018] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE The appropriate duration of antibiotic therapy for diabetic foot infections (DFI) after surgical amputations in toto is debated. There are discrepancies worldwide. METHODS Using a clinical pathway for adult DFI patients (retrospective cohort analysis), we conducted a cluster-controlled Cox regression analysis. Minimum follow-up was 2 months. RESULTS We followed 482 amputated DFI episodes for a median of 2.1 years after the index episode. The DFIs predominately affected the forefoot (n = 433; 90%). We diagnosed osteomyelitis in 239 cases (239/482; 50%). In total, 47 cases (10%) were complicated by bacteremia, 86 (18%) by abscesses and 139 (29%) presented with cellulitis. Surgical amputation involved the toes (n = 155), midfoot (280) and hindfoot (47). Overall, 178 cases (37%) required revascularization. After amputation, the median duration of antibiotic administration was 7 days (interquartile range, 1-16 days). In 109 cases (25%), antibiotics were discontinued immediately after surgery. Overall, clinical failure occurred in 90 DFIs (17%), due to the same pathogens in only 38 cases. In multivariate analysis, neither duration of total postsurgical antibiotic administration (HR 1.0, 95% CI 0.99-1.01) nor immediate postoperative discontinuation altered failure rate (HR 0.9, 0.5-1.5). CONCLUSION According to our clinical pathway, we found no benefit in continuing postsurgical antibiotic administration in routine amputation for DFI. In the absence of residual infection (ie, resection at clear margins), antibiotics should be discontinued.
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Affiliation(s)
- Anne Rossel
- Department of Internal MedicineGeneva University HospitalsGenevaSwitzerland
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
| | - Dan Lebowitz
- Department of Internal MedicineGeneva University HospitalsGenevaSwitzerland
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
| | - Karim Gariani
- Department of Internal MedicineGeneva University HospitalsGenevaSwitzerland
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
- Service of Diabetology and EndocrinologyGeneva University HospitalsGenevaSwitzerland
| | - Mohamed Abbas
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
- Infection Control ProgramGeneva University HospitalsGenevaSwitzerland
| | - Benjamin Kressmann
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
- Orthopaedic Surgery ServiceGeneva University HospitalsGenevaSwitzerland
- Clinical Pathway of Diabetic Foot InfectionsGeneva University HospitalsGenevaSwitzerland
| | - Mathieu Assal
- Orthopaedic Surgery ServiceGeneva University HospitalsGenevaSwitzerland
- La Colline Hirslanden ClinicGenevaSwitzerland
| | - Philippe Tscholl
- Orthopaedic Surgery ServiceGeneva University HospitalsGenevaSwitzerland
- Clinical Pathway of Diabetic Foot InfectionsGeneva University HospitalsGenevaSwitzerland
- Balgrist University HospitalZurichSwitzerland
| | - Dimitrios Stafylakis
- Orthopaedic Surgery ServiceGeneva University HospitalsGenevaSwitzerland
- Clinical Pathway of Diabetic Foot InfectionsGeneva University HospitalsGenevaSwitzerland
| | - Ilker Uçkay
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
- Infection Control ProgramGeneva University HospitalsGenevaSwitzerland
- Orthopaedic Surgery ServiceGeneva University HospitalsGenevaSwitzerland
- Clinical Pathway of Diabetic Foot InfectionsGeneva University HospitalsGenevaSwitzerland
- Balgrist University HospitalZurichSwitzerland
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17
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Papadopoulos A, Ribera A, Mavrogenis AF, Rodriguez-Pardo D, Bonnet E, Salles MJ, Dolores Del Toro M, Nguyen S, Blanco-García A, Skaliczki G, Soriano A, Benito N, Petersdorf S, Pasticci MB, Tattevin P, Tufan ZK, Chan M, O'Connell N, Pantazis N, Kyprianou A, Pigrau C, Megaloikonomos PD, Senneville E, Ariza J, Papagelopoulos PJ, Giannitsioti E. Multidrug-resistant and extensively drug-resistant Gram-negative prosthetic joint infections: Role of surgery and impact of colistin administration. Int J Antimicrob Agents 2019; 53:294-301. [PMID: 30395988 DOI: 10.1016/j.ijantimicag.2018.10.018] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/21/2018] [Accepted: 10/27/2018] [Indexed: 02/08/2023]
Abstract
Factors influencing treatment outcome of patients with Gram-negative bacterial (GNB) multidrug-resistant (MDR) and extensively drug-resistant (XDR) prosthetic joint infection (PJIs) were analysed. Data were collected (2000-2015) by 18 centres. Treatment success was analysed by surgery type for PJI, resistance (MDR/XDR) and antimicrobials (colistin/non-colistin) using logistic regression and survival analyses. A total of 131 patients (mean age 73.0 years, 35.9% male, 58.8% with co-morbidities) with MDR (n = 108) or XDR (n = 23) GNB PJI were assessed. The most common pathogens were Escherichia coli (33.6%), Pseudomonas aeruginosa (25.2%), Klebsiella pneumoniae (21.4%) and Enterobacter cloacae (17.6%). Pseudomonas aeruginosa predominated in XDR cases. Isolates were carbapenem-resistant (n = 12), fluoroquinolone-resistant (n = 63) and ESBL-producers (n = 94). Treatment outcome was worse in XDR versus MDR cases (P = 0.018). Success rates did not differ for colistin versus non-colistin in XDR cases (P = 0.657), but colistin was less successful in MDR cases (P = 0.018). Debridement, antibiotics and implant retention (DAIR) (n = 67) was associated with higher failure rates versus non-DAIR (n = 64) (OR = 3.57, 95% CI 1.68-7.58; P < 0.001). Superiority of non-DAIR was confirmed by Kaplan-Meir analysis (HR = 0.36, 95% CI 0.20-0.67) and remained unchangeable by time of infection (early/late), antimicrobial resistance (MDR/XDR) and antimicrobials (colistin/non-colistin) (Breslow-Day, P = 0.737). DAIR is associated with higher failure rates even in early MDR/XDR GNB PJIs versus implant removal. Colistin should be preserved for XDR cases as it is detrimental in MDR infections.
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Affiliation(s)
- Antonios Papadopoulos
- Fourth Department of Internal Medicine, University General Hospital 'ATTIKON', School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Alba Ribera
- Department of Infectious Diseases, Hospital Universitari Bellvitge, Barcelona, Spain
| | - Andreas F Mavrogenis
- First Department of Orthopaedics, University General Hospital 'ATTIKON', School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Dolors Rodriguez-Pardo
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Eric Bonnet
- Department of Infectious Diseases, Hôpital Joseph Ducuing, Toulouse, France
| | - Mauro José Salles
- Division of Infectious Diseases, Department of Internal Medicine, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - María Dolores Del Toro
- Infectious Diseases Unit, Hospital Universitario Virgen Macarena, Universidad de Sevilla, Instituto de Biomedicina de Sevilla (IBIS), Seville, Spain
| | - Sophie Nguyen
- Infectious Diseases Department, Gustave Dron Hospital, Tourcoing, France
| | - Antonio Blanco-García
- Bone and Joint Infection Unit, Department of Emergency Medicine, IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain
| | - Gábor Skaliczki
- Department of Orthopaedics, Semmelweis University, Budapest, Hungary
| | - Alejandro Soriano
- Department of Infectious Diseases, Hospital Clínic, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Natividad Benito
- Unit of Infectious Diseases, Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sabine Petersdorf
- Institute of Medical Microbiology and Hospital Hygiene, University Hospital, Heinrich-Heine-University, Düsseldorf, Germany
| | | | - Pierre Tattevin
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - Zeliha Kocak Tufan
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Yildirim Beyazit University, Ankara Ataturk Education and Research Hospital, Ankara, Turkey
| | - Monica Chan
- Department of Infectious Diseases, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore
| | - Nuala O'Connell
- Department of Clinical Microbiology, University Hospital Limerick, Limerick, Ireland
| | - Nikos Pantazis
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Aikaterini Kyprianou
- Fourth Department of Internal Medicine, University General Hospital 'ATTIKON', School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Carlos Pigrau
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Panayiotis D Megaloikonomos
- First Department of Orthopaedics, University General Hospital 'ATTIKON', School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Eric Senneville
- Infectious Diseases Department, Gustave Dron Hospital, Tourcoing, France
| | - Javier Ariza
- Department of Infectious Diseases, Hospital Universitari Bellvitge, Barcelona, Spain
| | - Panayiotis J Papagelopoulos
- First Department of Orthopaedics, University General Hospital 'ATTIKON', School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Efthymia Giannitsioti
- Fourth Department of Internal Medicine, University General Hospital 'ATTIKON', School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
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18
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Davat M, Wuarin L, Stafylakis D, Abbas M, Harbarth S, Hannouche D, Uçkay I. Should antibiotic prophylaxis before orthopedic implant surgery depend on the duration of pre-surgical hospital stay? Antimicrob Resist Infect Control 2018; 7:131. [PMID: 30455869 PMCID: PMC6223050 DOI: 10.1186/s13756-018-0421-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 10/11/2018] [Indexed: 11/19/2022] Open
Abstract
Background Prolonged hospital stay before surgery is a risk for colonization with antibiotic-resistant microorganisms and possible antibiotic-resistant surgical site infections (SSI), which lacks acknowledgement in international guidelines for perioperative antibiotic prophylaxis. Method Retrospective cohort study focusing on prophylaxis-resistant SSI in adult orthopedic implant patients; with emphasis on length of hospital stay prior to the index surgery. Results We enrolled 611 cases of SSI (median age, 65 years; 241 females and 161 immune-suppressed) in four large implant groups: arthroplasties (n = 309), plates (n = 127), spondylodeses (n = 31), and nails (n = 46). The causative pathogen was resistant to the perioperative antibiotic prophylaxis regimen in 307 cases (307/611; 50%), but the length of pre-surgical hospitalization did not influence the incidences of prophylaxis-resistant SSIs. These incidences were (107/211;51%) for the admission day, (170/345;49%) within 10 days of delay, (19/35;54%) between 10 and 20 days, and (11/20; 55%) beyond 20 days of hospital stay before surgery. The corresponding incidences of methicillin-resistant staphylococci were 13%, 14%, 17%, and 5%, respectively. In adjusted group comparisons, the length of prior hospital stay was equally unrelated to future prophylaxis-resistant SSI (odds ratio 1.0, 95% confidence interval 0.99-1.01). Conclusions In our retrospective cohort of orthopedic implant SSI, the length of pre-surgical hospital stay was unrelated to the incidence of prophylaxis-resistant pathogens.
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Affiliation(s)
- Marie Davat
- Orthopedic Surgery Service, Geneva University Hospitals, Geneva, Switzerland
| | - Lydia Wuarin
- Orthopedic Surgery Service, Geneva University Hospitals, Geneva, Switzerland
| | | | - Mohamed Abbas
- Infection Control Program, Geneva University Hospitals, Geneva, Switzerland
| | - Stephan Harbarth
- Infection Control Program, Geneva University Hospitals, Geneva, Switzerland
| | - Didier Hannouche
- Orthopedic Surgery Service, Geneva University Hospitals, Geneva, Switzerland
| | - Ilker Uçkay
- Infectiology, Balgrist University Hospital, Forchstrasse 340, 8008 Zürich, Switzerland
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19
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Thompson JM, Miller RJ, Ashbaugh AG, Dillen CA, Pickett JE, Wang Y, Ortines RV, Sterling RS, Francis KP, Bernthal NM, Cohen TS, Tkaczyk C, Yu L, Stover CK, DiGiandomenico A, Sellman BR, Thorek DL, Miller LS. Mouse model of Gram-negative prosthetic joint infection reveals therapeutic targets. JCI Insight 2018; 3:121737. [PMID: 30185667 DOI: 10.1172/jci.insight.121737] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 07/26/2018] [Indexed: 12/23/2022] Open
Abstract
Bacterial biofilm infections of implantable medical devices decrease the effectiveness of antibiotics, creating difficult-to-treat chronic infections. Prosthetic joint infections (PJI) are particularly problematic because they require prolonged antibiotic courses and reoperations to remove and replace the infected prostheses. Current models to study PJI focus on Gram-positive bacteria, but Gram-negative PJI (GN-PJI) are increasingly common and are often more difficult to treat, with worse clinical outcomes. Herein, we sought to develop a mouse model of GN-PJI to investigate the pathogenesis of these infections and identify potential therapeutic targets. An orthopedic-grade titanium implant was surgically placed in the femurs of mice, followed by infection of the knee joint with Pseudomonas aeruginosa or Escherichia coli. We found that in vitro biofilm-producing activity was associated with the development of an in vivo orthopedic implant infection characterized by bacterial infection of the bone/joint tissue, biofilm formation on the implants, reactive bone changes, and inflammatory immune cell infiltrates. In addition, a bispecific antibody targeting P. aeruginosa virulence factors (PcrV and Psl exopolysaccharide) reduced the bacterial burden in vivo. Taken together, our findings provide a preclinical model of GN-PJI and suggest the therapeutic potential of targeting biofilm-associated antigens.
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Affiliation(s)
| | | | | | | | - Julie E Pickett
- Department of Radiology and Radiological Sciences, Division of Nuclear Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yu Wang
- Department of Dermatology, and
| | | | | | - Kevin P Francis
- PerkinElmer, Hopkinton, Massachusetts, USA.,Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Santa Monica, California, USA
| | - Nicholas M Bernthal
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Santa Monica, California, USA
| | | | | | - Li Yu
- Statistical Sciences, MedImmune, Gaithersburg, Maryland, USA
| | | | | | | | - Daniel Lj Thorek
- Department of Radiology and Radiological Sciences, Division of Nuclear Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Cancer Molecular and Functional Imaging Program, Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, and
| | - Lloyd S Miller
- Department of Orthopaedic Surgery.,Department of Dermatology, and.,Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, Maryland, USA
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Sendi P, Borens O, Wahl P, Clauss M, Uçkay I. Management of Asymptomatic Bacteriuria, Urinary Catheters and Symptomatic Urinary Tract Infections in Patients Undergoing Surgery for Joint Replacement: A Position Paper of the Expert Group 'Infection' of swissorthopaedics. J Bone Jt Infect 2017; 2:154-159. [PMID: 28894690 PMCID: PMC5592375 DOI: 10.7150/jbji.20425] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 04/23/2017] [Indexed: 12/31/2022] Open
Abstract
In this position paper, we review definitions related to this subject and the corresponding literature. Our recommendations include the following statements. Asymptomatic bacteriuria, asymptomatic leukocyturia, urine discolouration, odd smell or positive nitrite sediments are not an indication for antimicrobial treatment. Antimicrobial treatment of asymptomatic bacteriuria does not prevent periprosthetic joint infection, but is associated with adverse events, costs and antibiotic resistance development. Urine analyses or urine cultures in asymptomatic patients undergoing orthopaedic implants should be avoided. Indwelling urinary catheters are the most frequent reason for healthcare-associated urinary tract infections and should be avoided or removed as soon as possible.
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Affiliation(s)
- Parham Sendi
- Department of Infectious Diseases, Bern University Hospital, University of Bern.,Institute for Infectious Diseases, University of Bern
| | - Olivier Borens
- Orthopedic Septic Surgical Unit, Department of Surgery and Anaesthesiology, Lausanne University Hospital, Lausanne
| | - Peter Wahl
- Division for Orthopaedic and Trauma Surgery, Cantonal Hospital Winterthur, Switzerland
| | - Martin Clauss
- Clinic for Orthopedics and Trauma Surgery and Interdisciplinary Septic Surgical Unit, Kantonsspital Baselland Liestal, Switzerland
| | - Ilker Uçkay
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva.,Orthopedic Surgery Service, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Switzerland
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