Is oral antibiotic therapy as effective as intravenous treatment in bacterial osteomyelitis? A real-life experience

OBJECTIVE

Osteomyelitis is a relatively understudied disease with no standardized and evidence-based approach to treatment. We aimed to evaluate a cohort of patients with osteomyelitis, comparing the outcomes between intravenous (IV) and oral treatment.

PATIENTS AND METHODS

We performed an observational retrospective study on osteomyelitis cases in adult patients seen for care between 2017 and 2019. We collected information on patient characteristics, microbiological etiology, infection treatment, and outcome. In addition, we divided osteomyelitis cases by antibiotic regimens [oral (OTG) vs. intravenous±oral (ITG)] and therapy durations to evaluate outcomes differences.

RESULTS

A total of 235 episodes of osteomyelitis were evaluated, with a higher prevalence in male gender. Staphylococci, especially S. aureus, were the most common strains. Out of the 235 evaluated episodes, we selected 142 cases. Of these, 75 were treated with OTG and 67 with ITG. Gram-positive bacteria were the most frequent aetiological agents, with 81 isolates (61.8%). Full recovery was observed in 79 (55.6%) cases; of these, 36 (53.7%) were in the ITG and 43 (57.3%) in the OTG (p = 0.666). At the logistic regression, a polymicrobial infection [OR 4.16 (95%CI 1.28-13.4), p = 0.017] and a less than six weeks treatment duration [OR 4.24 (95%CI 1.38-5.43) p = 0.004] were significantly associated with a higher risk of treatment failure.

CONCLUSIONS

Our study suggests that oral treatment efficacy is comparable to ITG therapy for osteomyelitis, confirming the most recent evidence suggesting that oral therapy is non-inferior to intravenous therapy to treat osteomyelitis.

Takotsubo cardiomyopathy: real life management in the intensive coronary care unit

AIM

Takotsubo cardiomyopathy is a cardiac syndrome characterized by reversible left ventricular dysfunction, ischemic changes on electrocardiogram, elevation of cardiac biomarkers, absence of obstructive coronary artery disease in the setting of various stressing conditions. To date, little is known on best clinical management of this syndrome in coronary care units. Whe thus aimed to present our experience in a real life takotsubo population.

METHODS

We identified all patients with Takotsubo cardiomyopathy at our center Maria Vittoria Hospital, Turin, between October 2006 and February 2012. Patients where considered to have Takotsubo syndrome if they presented chest pain on admission, new elettrocardiographic changes suggestive of myocardial ischemia, evidence of apical balloning with hyperkinesis of basal segments on echocardiography, rise in troponin I and, after coronary angiography, no coronary artery disease. We adjudicated the following clinical events: death and recurrence of ischemic events; we also made a detailed analysis of the stressing conditions leading to clinical syndrome.

RESULTS

A total of 26 patients were included, 4 (15%) males and 22 (85%) females; mean age was 71±13. After more than 1 year median follow-up the incidence of death was 7.7% (2 deaths), with all deaths, due to cardiogenic shock, occurring in the first 10 days of hospitalization; 2 patients (8%) experienced recurrence of ischemic event. Leading cause of Takostubo was major depressive episode (16%), followed by mourning (12%), falling down with difficulties in standing up (12%), vomiting (8%) and pulmonary infection (8%). In the coronary care unit major complications of patients with Takotsubo syndrome were acute hearth failure (62%), cardiogenic shock (27%), sepsis (31%), pulmonary aedema (27%) and anemia (12%). Two patients needed non-invasive ventilation support and one intra-aortic balloon conterpulasation. In addition one patient developed rabdomyolysis and one left heart thrombus. Cornerstone drug therapy was as follows: 96% of patients took aspirin, 58% beta blockers, 54% nitroglicerine, 46% intravenous heparin, 27% dopamine.

CONCLUSION

Takotsubo syndrome is an important safety issue occurring predominantly in post-menopausal women undergoing specific stressing condition. Heart failure and cardiogenic shock are the most serious clinical complication and leading cause of death in the short period, good prognosis is seen thereafter.

ExpIR-RO: A Collaborative International Project for Experimenting Voluntary Incident Reporting In the Public Healthcare Sector in Romania

BACKGROUND

Patient safety within healthcare systems is a central aspect of health policy in most developed countries. From April 2007 to May 2009, the pilot project ExpIR-RO tested a voluntary incident reporting system in a public hospital in Bucharest Romania, in collaboration with two Italian hospitals (in Genoa and Milan).

METHODS

Data were collected anonymously through a form based on the Australian Incident Monitoring System. After appropriate training in reporting adverse events (AEs), staff in the participating Departments voluntarily completed the form. The study lasted 12 months in the Bucharest and Genoa hospitals and 3 months in the Milan hospital. Frequency distributions of replies and AE rates per 1,000 hospitalization days per month were assessed.

RESULTS

Overall, 185 AEs were reported (58 in Bucharest, 75 in Genoa and 52 in Milan). The corresponding rates (per 1,000 hospitalization days per month) were 1 in Bucharest, 3 in Genoa and 15 in Milan. Most AEs were related to diagnostic (28%) and surgical (14%) procedures and patient falls (12%) in Bucharest; patient falls (32%), nursing care (20%) and diagnostic procedures (19%) in Genoa; and nursing care (25%), drug prescription/administration (21%) and diagnostic procedures (17%) in Milan. Seventy-three per cent of respondents in Bucharest informed the patient of the AE, versus 64% in Genoa and 43% in Milan. Conversely, 75% of respondents in Genoa entered AEs in medical records versus 53% in Bucharest and 36% in Milan.

CONCLUSION

ExpIR-RO experience suggests that incident reporting could be introduced on a larger scale in Romania.

Clopidogrel treatment in a patient with ticlopidine-induced hepatitis following percutaneous coronary stenting

Thienopyridines are commonly prescribed antiplatelets drugs, extremely useful for the acute and chronic management of patients with cerebrovascular and cardiovascular diseases. The occurrence of their side effects is fortunately uncommon, although unpredictable. We thereby describe a case of prescription of clopidogrel in a patient with ticlopidine-induced hepatitis confirmed by liver biopsy that had undergone multiple percutaneous coronary stenting procedures necessitating subsequent compulsory antiplatelets treatment. The description of this exceptional clinical case is of relevant knowledge to orientate a physician treating a patient with absolute need of antiplatelets and history of previous drug-induced reactions.

Safety of coronary collateral stenting in a patient with acute coronary syndrome

A protective role of the presence of collateral arteries, generating smaller infarcts, improved ventricular function, fewer future cardiovascular events, and improved survival following a myocardial ischemia has been described in numerous reports. However little is known about atherosclerotic disease of the collateral vessels, and the possibility to treat critical stenosis of these vessels has never been described. Therefore this report describes a unique case of percutaneous coronary intervention on a well developed yet atherosclerotic coronary collateral vessel triggering an acute coronary syndrome with hemodynamic instability. In the present case balloon angioplasty and stenting of the collateral vessel was safe and effective. Nonetheless, further studies are warranted.

Iatrogenic coronary-to-right ventricle fistula: benign outcome irrespective of patency?

Coronary perforation is an uncommon, but potentially lethal complication of percutaneous coronary interventions. Most perforations have proved to lead to intramyocardial or intrapericardial extravasation. However, perforation may also lead to direct coronary-to-right ventricle fistula, more commonly occurring in complex lesions and/or the use of atheroablative devices. To prevent this complication careful manipulation of the guidewire across the obstruction is mandatory, together with avoidance of oversized balloons and high-pressure inflations. The factors that determine the hemodynamic significance of the fistulas include size of the communication, resistance of the recipient chamber, and potential for development of myocardial ischemia. Accordingly a broad range of signs and symptoms may be referred. Despite iatrogenic fistulas are usually benign and asymptomatic, spontaneous closures are very rare. In most cases fistulas need to be treated by percutaneous or surgical closure, being the conservative management a debated option. In isolated cases serious complications have been described resulting from volume overload and distal myocardial flow impairment. We hereby describe two cases of coronary-to-right ventricle fistula occurred during percutaneous coronary intervention, highlighting full angiographic iconography and the issues involved in the management and follow-up of this iatrogenic complication.