Ana Lucia Munhoz Lima

Epidemiology of septic arthritis of the knee at Hospital das Clinicas, Universidade de Sao Paulo

BACKGROUNDnSeptic arthritis is an infrequent disease although very important due to the possibility of disastrous outcomes if treatment is not adequately established. Adequate information concerning the epidemiology of septic arthritis is still lacking due to the uncommon nature of the disease as well as the struggle to establish a correct case-definition.nnnOBJECTIVEnTo epidemiologically characterize the population seen at Hospital das Clínicas, University of São Paulo with a diagnosis of septic arthritis between 2006 and 2011.nnnMETHODSnSixty-one patients diagnosed with septic arthritis of the knee between 2006 and 2011 were retrospectively evaluated. The patients clinical and epidemiological characteristics, the microorganisms that caused the infection and the patients treatment and evolution were analyzed.nnnRESULTSnSeptic arthritis of the knee was more common among men, with distribution across a variety of age ranges. Most diagnoses were made through positive synovial fluid cultures. The most prevalent clinical comorbidities were systemic arterial hypertension and diabetes mellitus, and the most commonly reported joint disease was osteoarthritis. Staphylococcus aureus was the prevailing pathogen. Fever was present in 36% of the cases. All patients presented elevation in inflammatory tests. Gram staining was positive in only 50.8% of the synovial fluid samples analyzed. Six patients presented complications and unfavorable evolution of their condition.nnnCONCLUSIONnS. aureus is still the most common pathogen in acute knee infections in our environment. Gram staining, absence of fever and normal leukocyte count cannot be used to rule out septic arthritis.

Clinical and epidemiological differences between septic arthritis of the knee and hip caused by oxacillin-sensitive and -resistant s. aureus

OBJECTIVE: To establish the risk factors for joint infection by oxacillin-resistant Staphylococcus aureus (MRSA) using clinical and epidemiological data. METHODS: All septic arthritis cases of the knee and hip diagnosed and treated in our institution from 2006 to 2012 were evaluated retrospectively. Only patients with cultures identified as microbial agents were included in the study. The clinical and epidemiological characteristics of the patients were analyzed, seeking the differences between populations affected by MRSA and oxacillin-sensitive Staphylococcus aureus (MSSA). RESULTS: S. aureus was isolated in thirty-five patients (46.0%) in our total sample, 25 in the knee and 10 in the hip. Of these 35 patients, 22 presented with MSSA and 13 presented with MRSA. Provenance from a health service-related environment, as described by the Centers for Disease Control and Prevention, was the only variable associated with oxacillin-resistant strains of this bacterium (pu200a=u200a0.001). CONCLUSION: Provenance from a health service-related environment was associated with a higher incidence of MRSA-related septic arthritis, suggesting that this agent should be considered in the initial choice of antibiotic treatment. Previous surgeries of the knee or affected limb and the absence of leukocytes might also be related to infection with this agent.

Impact of restriction of cefepime use on the antimicrobial susceptibility of gram-negative bacilli related to healthcare-associated infections in an orthopedic hospital

Introduction: In recent decades, antimicrobial resistance has become a public health problem, particularly in cases of healthcare-associated infections. Interaction between antibiotic consumption and resistance development is of particular interest regarding Gram-negative bacilli, whose growing resistance has represented a great challenge. Objective: Assess the impact of restriction of cefepime use on antimicrobial susceptibility among the Gram-negative bacilli (GNB) most frequently involved in healthcare-associated infections (HAI). Methods: Data relating to hospital occupancy and mortality rates, incidence of HAI, incidence of GNB as causative agents of HAI, antimicrobial consumption at the hospital and antimicrobial susceptibility of GNB related to HAI were compared between two periods: a 24-month period preceding restriction of cefepime use and a 24-month period subsequent to this restriction. Results: There was a significant drop in cefepime consumption after its restriction. Susceptibility of Acinetobacter baumanii improved relating to gentamicin, but it worsened in relation to imipenem, subsequent to this restriction. For Pseudomonas aeruginosa, there was no change in antimicrobial susceptibility. For Klebsiella pneumoniae and Enterobacter spp, there were improvements in susceptibility relating to ciprofloxacin. Conclusion: Restriction of cefepime use had a positive impact on K. pneumoniae and Enterobacter spp, given that after this restriction, their susceptibilities to ciprofloxacin improved. However, for A. baumanii, the impact was negative, given the worsening of susceptibility to imipenem.

Septic arthritis of the knee: clinical and laboratory comparison of groups with different etiologies

OBJECTIVES: To clinically and epidemiologically characterize a population diagnosed with and treated for septic arthritis of the knee, to evaluate the treatment results and to analyze the differences between patients with positive and negative culture results, patients with Gram-positive and Gram-negative bacterial isolates and patients with S. aureus- and non-S. aureus-related infections. METHODS: One hundred and five patients with septic knee arthritis were included in this study. The clinical and epidemiological data were evaluated. Statistical analysis was performed to compare patients with and without an isolated causative agent, patients with Gram-positive and Gram-negative pathogens and patients with S. aureus-related and non S. aureus-related infections. RESULTS: Causative agents were isolated in 81 patients. Gram-positive bacteria were isolated in 65 patients and Gram-negative bacteria were isolated in 16 patients. The most commonly isolated bacterium was S. aureus. Comparing cases with an isolated pathogen to cases without an isolated pathogen, no differences between the studied variables were found except for the longer hospital stays of patients in whom an etiological agent was identified. When comparing Gram-positive bacteria with Gram-negative bacteria, patients with Gram-positive-related infections exhibited higher leukocyte counts. Patients with S. aureus-related infections were more frequently associated with healthcare-related environmental encounters. CONCLUSION: S. aureus is the most common pathogen of septic knee arthritis. Major differences were not observed between infections with isolated and non-isolated pathogens and between infections with Gram-positive and Gram-negative bacteria. S. aureus infections were more likely to be associated with a prior healthcare environment exposure.

Diabetic limb salvage procedure with bone allograft and free flap transfer: a case report

ABSTRACT The aim of this case report was to describe a successful diabetic limb salvage procedure in the treatment of an infected diabetic foot ulcer through a multidisciplinary team approach and complex surgical reconstruction involving a femoral head bone allograft and musculocutaneous latissimus dorsi free flap. The decision to proceed with aggressive staged efforts at diabetic limb salvage should be made only after careful consultation with the patient, his or her family, and the rest of the multidisciplinary healthcare team.

A new low-cost negative-pressure wound therapy versus a commercially available therapy device widely used to treat complex traumatic injuries: a prospective, randomized, non-inferiority trial

OBJECTIVES: Negative-pressure wound therapy has been widely adopted to reduce the complexity of treating a broad range of acute and chronic wounds. However, its cost is high. The objective of this study was to evaluate the following two different methods of negative-pressure wound therapy in terms of healing time: a low-cost method of negative-pressure wound therapy (a pressure stabilizer device connected to a hospital wall-vacuum system with a gauze-sealed dressing, USP) and the standard of care (vacuum-assisted closure, VAC). METHODS: This is a randomized, controlled, non-inferiority, unblinded trial. Patients admitted with complex injuries to a trauma center in a public referral hospital who were indicated for orthopedic surgery were randomized to a USP or VAC group. The primary outcome was the time required to achieve a “ready for surgery condition”, which was defined as a wound bed with healthy granulation tissue and without necrosis or purulent secretion. Wound bed area contraction, granulation tissue growth and the direct costs of the dressings were secondary outcomes. RESULTS: Variation in area and granulation tissue growth were essentially the same between the systems, and healing time was equal between the groups (p=0.379). In both systems, serial debridement increased wound area (p=0.934), and granulation tissue was also increased (p=0.408). The mean treatment cost was US

Septic arthritis of the shoulder and elbow: one decade of epidemiological analysis at a tertiary referral hospital

15.15 in the USP group and US

Optimizing the treatment of osteomyelitis with antimicrobial drugs: current concepts

872.59 in the VAC group. CONCLUSIONS: For treating complex traumatic injuries, USP was non-inferior to and less expensive than VAC.

Recommendations for outpatient parenteral antimicrobial therapy in Brazil

Objective To describe the clinical and epidemiological characteristics of patients with septic arthritis of the shoulder or elbow and to evaluate prognostic factors for complications during treatment. Methods A retrospective case series was studied with patients treated between 2004 and 2014. The patients’ clinical and epidemiological characteristics were collected. The clinical and orthopedic complications were identified and possible prognostic factors were evaluated. Results Twenty-seven patients were analyzed, 17 with septic arthritis of the shoulder and ten of the elbow. Median age was 46 years (IQR, 24.5; 61). Previous joint disease was observed in nine patients (33%). At least one clinical comorbidity was observed in 23 patients (85%). Staphylococcus aureus was identified in 14 cases (52%). Fourteen patients (52%) had at least one clinical complication and five patients died (19%). Nine patients (33%) had some type of orthopedic complication. The time between onset of symptoms and surgical treatment was longer in patients with orthopedic complications (p = 0.020). Regarding the development of clinical complications, leukocytosis on hospital admission time (p = 0.021) and the presence of clinical morbidities (p = 0.041) were predictive factors. Conclusions Septic arthritis of the shoulder and elbow primarily affects individuals who are immunocompromised and/or have clinical comorbidities. S. aureus is the most common pathogen in Brazil. Leukocytosis at hospital admission and the presence of clinical comorbidities are factors associated with the presence of clinical complications. Longer time between onset of symptoms and surgical treatment was correlated with orthopedic complications.

Avascular necrosis of the femoral head in HIV-infected patients: preliminary results from surgical treatment for ceramic-ceramic joint replacement

The success of osteomyelitis treatment, particularly in cases related to implants, depends on extensive surgical debridement and adequate and effective antibiotic therapy. Direct administration of antimicrobial agents through their incorporation into orthopaedic cement is an important adjuvant therapy. The capacity for biofilm to form by causative agents of osteomyelitis is an obstacle to antimicrobial treatment of these infections. Bacteria present in biofilm usually has greater bacterial resistance and higher expression of virulence factors than sessile bacteria, as well as mechanisms to escape the host immune response. The ability of causative agents of infection, particularly Staphylococcus aureus, to form small colony variants (SCV), a phenotype capable of invading and infecting osteoblasts, is another important mechanism that contributes to exacerbation of osteomyelitis to a chronic state. To optimize the antimicrobial treatment of osteomyelitis and improve patients’ prognosis, it is fundamental to consider these complicating factors, as well as the antimicrobial susceptibility profile of the causative microorganisms. Rifampicin should always be considered as part of the therapeutic regimen because it presents good bone concentration and has proven capacity to act on strains present in biofilm and in SCV.