Ana Lucia Lei Munhoz Lima

Prospective study of the treatment of infected hip arthroplasties with or without the use of an antibiotic-loaded cement spacer

PURPOSE Our purpose was to compare 2 methods of treatment of chronic infection in hip arthroplasties--with or without an antibiotic-loaded cement spacer. METHODS In a prospective study, we treated 68 infected hip arthroplasties with discharging sinuses and bone loss, comparing 30 patients treated in 2 stages without the use of a spacer (control group) and 38 patients treated with a vancomycin-loaded spacer (study group). The average follow-up was 4 years (2-8.5 years). One patient died of unrelated causes 4 months after first-stage surgery and was excluded from the study. RESULTS The 2-stage surgery without spacer controlled the infection in 66.7% of patients, and the 2-stage surgery using the spacer controlled it in 89.1% (P < 0.05). At last follow-up, the average Harris Hip Score increased from 19.3 to 69.0 in the control group versus 19.7 to 75.2 in the study group (P > 0.05). The average leg length discrepancy was 2.6 cm in the control group and 1.5 cm in the study group (P < 0.05). The patients treated with a spacer had better clinical results (81.5% of patients with good results against 60.0% for the control group). CONCLUSION The use of an antibiotic-loaded spacer in the 2-stage treatment of infected hip arthroplasties provides better infection control with good functional results and is superior to treatment in 2 stages without a spacer. LEVEL OF EVIDENCE Therapeutic study, Level I-1.

One-Stage Revision of Infected Total Hip Arthroplasty with Bone Graft

There are many different opinions in the literature regarding the best procedure for revision of infected hip arthroplasty and hence in achieving long-term stabilization of a new implant. Thirty-two patients with 32 loose and infected total hip arthroplasties underwent revision with a bone graft in a 1-stage procedure. The bone graft was used in the acetabulum and femur in 25 patients, in the acetabulum alone in 4 patients and in the femur alone in 3 patients. A metal mesh was necessary in 15 patients to contain the morselized bone graft. At the time of surgical revision, 9 patients had a draining sinus, 6 had a closed sinus, and 17 had never had sinuses in the surgical wound. Antibiotic therapy was administered intravenously and orally for 6 months. Mean follow-up was 103 months (range, 63-183 months), and infection recurred in 2 (6.2%) cases. Further studies are necessary, and continuation of this method is justified.

Carbapenem stewardship: does ertapenem affect Pseudomonas susceptibility to other carbapenems? A review of the evidence

The group 2 carbapenems (imipenem, meropenem and, more recently, doripenem) have been a mainstay of treatment for patients with serious hospital infections caused by Pseudomonas aeruginosa, Enterobacteriaceae and other difficult-to-treat Gram-negative pathogens as well as mixed aerobic/anaerobic infections. When ertapenem, a group 1 carbapenem, was introduced, questions were raised about the potential for ertapenem to select for imipenem- and meropenem-resistant Pseudomonas. Results from ten clinical studies evaluating the effect of ertapenem use on the susceptibility of Pseudomonas to carbapenems have uniformly shown that ertapenem use does not result in decreased Pseudomonas susceptibility to these antipseudomonal carbapenems. Here we review these studies evaluating the evidence of how ertapenem use affects P. aeruginosa as well as provide considerations for ertapenem use in the context of institutional stewardship initiatives.

Periprosthetic Joint Infections

Implantation of joint prostheses is becoming increasingly common, especially for the hip and knee. Infection is considered to be the most devastating of prosthesis-related complications, leading to prolonged hospitalization, repeated surgical intervention, and even definitive loss of the implant. The main risk factors to periprosthetic joint infections (PJIs) are advanced age, malnutrition, obesity, diabetes mellitus, HIV infection at an advanced stage, presence of distant infectious foci, and antecedents of arthroscopy or infection in previous arthroplasty. Joint prostheses can become infected through three different routes: direct implantation, hematogenic infection, and reactivation of latent infection. Gram-positive bacteria predominate in cases of PJI, mainly Staphylococcus aureus and Staphylococcus epidermidis. PJIs present characteristic signs that can be divided into acute and chronic manifestations. The main imaging method used in diagnosing joint prosthesis infections is X-ray. Computed tomography (CT) scan may assist in distinguishing between septic and aseptic loosening. Three-phase bone scintigraphy using technetium has high sensitivity, but low specificity. Positron emission tomography using fluorodeoxyglucose (FDG-PET) presents very divergent results in the literature. Definitive diagnosis of infection should be made by isolating the microorganism through cultures on material obtained from joint fluid puncturing, surgical wound secretions, surgical debridement procedures, or sonication fluid. Success in treating PJI depends on extensive surgical debridement and adequate and effective antibiotic therapy. Treatment in two stages using a spacer is recommended for most chronic infections in arthroplasty cases. Treatment in a single procedure is appropriate in carefully selected cases.

Recommendations for the treatment of osteomyelitis

With the advances in surgical treatment, antibiotic therapy and the current resources for accurate diagnosis and differentiated approaches to each type of osteomyelitis, better results are being obtained in the treatment of this disease. After a careful literature review carried out by a multiprofessional team, some conclusions were made in order to guide medical approach to different types of osteomyelitis, aiming to obtain better clinical outcomes and reducing the social costs of this disease. Acute and chronic osteomyelitis are discussed, with presentation of the general epidemiological concepts and the commonly used classification systems. The main guidelines for the clinical, laboratory and imaging diagnosis of infections are discussed, as well as the guidelines for surgical and antimicrobial treatments, and the role of hyperbaric oxygen as adjuvant therapy.

The impact of ertapenem use on the susceptibility of Pseudomonas aeruginosa to imipenem: a hospital case study.

We sought to evaluate the indirect impact of ertapenem use for the treatment of extended-spectrum beta-lactamase-producing Enterobacteriaceae infections in our hospital on the susceptibility of Pseudomonas aeruginosa to imipenem. The use of ertapenem was mandated for treatment of extended-spectrum beta-lactamase-producing Enterobacteriaceae infections in the absence of nonfermenting gram-negative bacilli for 1 year. The use of imipenem was restricted. Imipenem consumption decreased 64.5%. Ertapenem consumption was 42.57 defined daily doses per 1,000 patient-days. None of the 18 P. aeruginosa isolates recovered after ertapenem introduction were imipenem-resistant, compared with 4 of the 20 P. aeruginosa isolates recovered in the previous year.

Carbapenem stewardship: positive impact on hospital ecology

INTRODUCTION Excessive group 2 carbapenem use may result in decreased bacterial susceptibility. OBJECTIVE We evaluated the impact of a carbapenem stewardship program, restricting imipenem and meropenem use. METHODS Ertapenem was mandated for ESBL-producing Enterobacteriaceae infections in the absence of non-fermenting Gram-negative bacilli (GNB) from April 2006 to March 2008. Group 2 carbapenems were restricted for use against GNB infections susceptible only to carbapenems and suspected GNB infections in unstable patients. Cumulative susceptibility tests were done for nosocomial pathogens before and after restriction using Clinical and Laboratory Standards Institute (CLSI) guide-lines.Vitek System or conventional identification methods were performed and susceptibility testing done by disk diffusion according to CLSI.Antibiotic consumption (t-test) and susceptibilities (McNemars test) were determined. RESULTS The defined daily doses (DDD) of group 2 carbapenems declined from 61.1 to 48.7 DDD/1,000 patient-days two years after ertapenem introduction (p = 0.027). Mean ertapenem consumption after restriction was 31.5 DDD/1,000 patient-days. Following ertapenem introduction no significant susceptibility changes were noticed among Gram-positive cocci. The most prevalent GNB were P. aeruginosa, Klebsiella pneumoniae, and Acinetobacter spp. There was no change in P. aeruginosa susceptibility to carbapenems. Significantly improved P. aeruginosa and K. pneumoniae ciprofloxacin susceptibilities were observed, perhaps due to decreased group 2 carbapenem use. K. pneumoniae susceptibility to trimethoprim-sulfamethoxazole improved. CONCLUSION Preferential use of ertapenem resulted in reduced group 2 carbapenem use, with a positive impact on P. aeruginosa and K. pneumoniae susceptibility.

Economic impact of treatment for surgical site infections in cases of total knee arthroplasty in a tertiary public hospital in Brazil

The aim of this study was to estimate the additional cost of treatment of a group of nosocomial infections in a tertiary public hospital. A retrospective observational cohort study was conducted by means of analyzing the medical records of 34 patients with infection after total knee arthroplasty, diagnosed in 2006 and 2007, who met the criteria for nosocomial infection according to the Centers for Disease Control and Prevention. To estimate the direct costs of treatment for these patients, the following data were gathered: length of hospital stay, laboratory tests, imaging examinations, and surgical procedures performed. Their costs were estimated from the minimum values according to the Brazilian Medical Association. The estimated cost of the antibiotics used was also obtained. The total length of stay in the ward was 976 days, at a cost of US

Tratamento das infecções pós artroplastia total de joelho: resultados com 2 anos de seguimento

18,994.63, and, in the intensive care unit, it was 34 days at a cost of US

Infecção pós-artoplastia total do joelho: considerações e protocolo de tratamento

5,031.37. Forty-two debridement procedures were performed, at a cost of US