Carlos Pigrau

Early prosthetic joint infection: outcomes with debridement and implant retention followed by antibiotic therapy

Recent expert reviews recommend a conservative surgical strategy - debridement and irrigation, antibiotics and implant retention (DAIR) - for most early post-surgical prosthetic joint infections (PJI). However, differences exist in published series regarding success rates with DAIR, and the size of most series is small. In this prospective multicenter cohort study of early PJI managed by DAIR, factors associated with failure of the DAIR were analyzed. Out of 139 early PJI, 117 cases managed with DAIR were studied For 67 patients (57.3%), infection was cured and the implant was salvaged with definite antimicrobial therapy. In 35 (29.9%) DAIR failed and removal of the prosthesis was necessary during follow-up. Finally, 15 patients (12.8%) needed chronic suppressive antimicrobial therapy due to suspected or confirmed persistent infection. Infections due to methicillin-resistant S. aureus (72.7% failed; p 0.05) and those treated at one of the hospitals (80.0% failed; p <0.05) had worse outcomes, but only this last variable was associated with treatment failure following multivariate analysis. Seventy-four per cent of patients who were successfully treated by DAIR and only 32.7% of the failures were able to walk without help or with one stick at the last follow-up visit (p <0.05). In conclusion, a substantial proportion of patients with an early PJI may be successfully treated with DAIR and definite antimicrobial therapy. In more than half of these, the infection can be cured. Since identification of factors associated with failure of DAIR is not simple, we recommend offering DAIR to most patients with early PJI.

Acute haematogenous prosthetic joint infection: prospective evaluation of medical and surgical management

The optimum treatment for prosthetic joint infections has not been clearly defined. We report our experience of the management of acute haematogenous prosthetic joint infection (AHPJI) in patients during a 3-year prospective study in nine Spanish hospitals. Fifty patients, of whom 30 (60%) were female, with a median age of 76 years, were diagnosed with AHPJI. The median infection-free period following joint replacement was 4.9 years. Symptoms were acute in all cases. A distant previous infection and/or bacteraemia were identified in 48%. The aetiology was as follows: Staphylococcus aureus, 19; Streptococcus spp., 14; Gram-negative bacilli, 12; anaerobes, two; and mixed infections, three. Thirty-four (68%) patients were treated with a conservative surgical approach (CSA) with implant retention, and 16 had prosthesis removal. At 2-year follow-up, 24 (48%) were cured, seven (14%) had relapsed, seven (14%) had died, five (10%) had persistent infection, five had re-infection, and two had an unknown evolution. Overall, the treatment failure rates were 57.8% in staphylococcal infections and 14.3% in streptococcal infections. There were no failures in patients with Gram-negative bacillary. By multivariate analysis, CSA was the only factor independently associated with treatment failure (OR 11.6; 95% CI 1.29-104.8). We were unable to identify any factors predicting treatment failure in CSA patients, although a Gram-negative bacillary aetiology was a protective factor. These data suggest that although conservative surgery was the only factor independently associated with treatment failure, it could be the first therapeutic choice for the management of Gram-negative bacillary and streptococcal AHPJI, and for some cases with acute S. aureus infections.

Tuberculous trochanteric bursitis: report of 5 cases and literature review.

Tuberculous trochanteric bursitis (TTB) is a rare condition. Clinical management varies considerably and recurrence is common. This report presents 5 new cases of TTB and a review of the literature (1981–2003), with emphasis on clinical and radiological findings and treatment, in order to investigate the optimum therapeutic approach.

Oxazolidinonas y glucopéptidos

(dose adjustments are needed in renal failure). The main clinical indications are the treatment of infections caused by grampositive pathogens; linezolid is also useful for infections caused by glycopeptide-resistant enterococcal infections. Linezolid can cause trombocytopenia when treatment lasted longer than two weeks. The main side effect of vancomycin is its nefrotoxicity and teicoplanin can cause fever.

Streptococcs bovis Bacteremia and Digestive System Neoplasms

(1988). Streptococcs bovis Bacteremia and Digestive System Neoplasms. Scandinavian Journal of Infectious Diseases: Vol. 20, No. 4, pp. 459-460.

Health care associated hematogenous pyogenic vertebral osteomyelitis: a severe and potentially preventable infectious disease.

AbstractAlthough hematogenous pyogenic spinal infections have been related to hemodialysis (HD), catheter-related sepsis, and sporadically, to other nosocomial infections or procedures, in most recent studies and reviews the impact of nosocomial infection as a risk factor for vertebral osteomyelitis (VO) is not well established. The aim of our study was to describe the risk factors, infectious source, etiology, clinical features, therapy, and outcome of health care associated VO (HCAVO), and compare them with community-acquired VO (CAVO) cases.A retrospective cohort study of consecutive patients with hematogenous VO was conducted in our third-level hospital between 1987 and 2011. HCAVO was defined as onset of symptoms after 1 month of hospitalization or within 6 months after hospital discharge, or ambulatory manipulations in the 6 months before the diagnosis.Over the 25-year study period, among 163 hematogenous pyogenic VO, 41 (25%) were health care associated, a percentage that increased from 15% (9/61) in the 1987–1999 period to 31% (32/102) in the 2000–2011 period (P < 0.01). The presumed source of infection was an intravenous catheter in 14 (34%), cutaneous foci in 8 (20%), urinary tract in 7 (17%), gastrointestinal in 3 (7%), other foci in 3 (7%), and unknown in 6 (15%). Staphylococcus aureus was the most frequently isolated microorganism (14 cases, 34%), followed by coagulase-negative Staphylococci (CoNS) in 6 (15%), and Enterobacteriaceae in 6 (15%) cases.Compared with CAVO cases, patients with HCAVO were older (mean 66.0 SD 13.0 years vs 60.5 SD 15.5 years), had more underlying conditions (73% vs 50%, P < 0.05), neoplasm/immunosuppression (39% vs 7%, P < 0.005), chronic renal failure (19% vs 4%, P < 0.001), a known source of infection (85% vs 54% P < 0.05), Candida spp (7% vs 0%, P < 0.01) or CoNS infections (15% vs 2%, P < 0.05), higher mortality (15% vs 6%, P = 0.069), and a higher relapse rate in survivors (9% vs 1%, P < 0.05).Presently, in our setting, one-third of hematogenous pyogenic VO infections are health care associated, and a third of these are potentially preventable catheter-related infections. Compared with CAVO, in health care associated hematogenous VO, mortality and relapse rates are higher; hence, further prevention measures should be assessed.

Osteomielitis vertebral por Candida spp.

Introduccion La osteomielitis vertebral por Candida spp. es una rara entidad que requiere de un alto indice de sospecha para su diagnostico. Metodos Descripcion de 3 casos de osteomielitis vertebral por Candida spp. diagnosticados durante un periodo de 17 anos. Resultados De 110 episodios de osteomielitis, tres fueron causadas por Candida spp. Los 3 pacientes presentaban factores predisponentes: diabetes mellitus (2/3), inmunosupresion (2/3), cateteres centrales (3/3), antibioticoterapia (2/3) y nutricion parenteral (2/3). El diagnostico se establecio mediante tecnicas de imagen y cultivo de la lesion vertebral en 2 casos y en el tercero, afectado de endocarditis aortica, por la presencia de hemocultivos positivos. En 2 pacientes la evolucion fue favorable con tratamiento medico y el tercero recidivo tras 6 meses de tratamiento con fluconazol. Conclusion La osteomielitis por Candida spp. es poco frecuente y debe sospecharse en pacientes con factores de riesgo para desarrollar una candidemia.

Sternotomy infection due toMycoplasma hominis andUreaplasma urealyticum

Mycoplasma hominis infections outside the urogenital tract are uncommon. An unusual case of sternal infection caused by bothMycoplasma hominis andUreaplasma urealyticum is described. This is the first report found in the literature of mixed infection due to these microorganisms at this site. The outcome was favourable after drainage of the surgical wound and antibiotic therapy with clindamycin, gentamicin and doxycycline.

Infecciones asociadas a dispositivos para drenaje de las vías urinarias. Infecciones del tracto genital relacionadas con los dispositivos protésicos

La infeccion urinaria (IU) nosocomial se relacionafundamentalmente con la utilizacion de la sonda urinaria (SU). En este capitulo se repasan los mecanismos patogenicos por los cuales los microorganismos alcanzan el tracto urinario, asi como la capacidad de adhesion y de formacion de biopeliculas, lo cual depende tanto del microorganismo como del tipo de SU. En la etiologia de la IU del paciente sondado intervienen multiples microorganismos, lo cual dificulta la eleccion de un tratamiento empirico adecuado, especialmente si se sospecha infeccion por microorganismos multirresistentes. En el sondado las manifestaciones clinicas son menos caracteristicas y el diagnostico, a menudo, dificil. La terapia debera estratificarse segun el tipo de IU; mientras la bacteriuria asintomatica no requiere habitualmente de tratamiento, en el paciente con shock septico la cobertura debera ser amplia. Se efectua, asimismo, un amplio repaso de las medidas preventivas. Las infecciones del tracto genital relacionadas con dispositivos protesicos se han asociado fundamentalmente a la utilizacion de dispositivos intrauterinos (DIU). En este apartado se repasa la epidemiologia, la etiologia, el tratamiento y la prevencion de las infecciones asociadas a la utilizacion de DIU.

Infecciones de piel y partes blandas por grampositivos multirresistentes

Staphylococcus aureus resistente a meticilina (SARM) es el microorganismo grampositivo multirresistente de mayor prevalencia en las infecciones de la piel y los tejidos blandos. En este capitulo se comentan las alteraciones geneticas, los factores de virulencia y la epidemiologia del SARM adquirido en la comunidad, que en la actualidad es la etiologia mas frecuente de las infecciones cutaneas supuradas en Estados Unidos y que ha hecho que en este pais se proceda a replantear el tratamiento empirico idoneo de estas infecciones. Asimismo, se comentan la epidemiologia y las manifestaciones cutaneas del SARM adquirido en el hospital. Se discute el papel de farmacos clasicos como la vancomicina, la teicoplanina y tambien el cotrimoxazol o la clindamicina en el tratamiento de las infecciones de la piel y los tejidos blandos, tanto comunitarias como las adquiridas en el hospital, y la aportacion de los nuevos antibioticos: linezolid, daptomicina, tigeciclina, ceftobiprole y los nuevos glucopeptidos: telavancina y dalbavancina. Por ultimo se realiza un breve comentario sobre otras medidas adyuvantes en el tratamiento de las formas graves de las infecciones de la piel y los tejidos blandos.