John Segreti

Diagnosis of periprosthetic joint infections of the hip and knee.

&NA; No preferred test for diagnosis of periprosthetic joint infection exists, and the algorithm for the workup of patients suspected of infection remains unclear. The work group evaluated the available literature to determine the role of each diagnostic modality and devise a practical algorithm that allows physicians to reach diagnosis of periprosthetic joint infection. Ten of the 15 recommendations have strong or moderate evidence in support. These include matters involving erythrocyte sedimentation rate and C‐reactive protein level testing, knee and hip aspiration, and stopping the use of antibiotics prior to obtaining intra‐articular cultures. The group recommends against the use of intraoperative Gram stain but does recommend the use of frozen sections of peri‐implant tissues in reoperation patients in whom infection has not been established, as well as multiple cultures in reoperation patients being assessed for infection. The group recommends against initiating antibiotic treatment in patients with suspected infection until after joint cultures have been obtained, but recommends that prophylactic preop‐erative antibiotics not be withheld in patients at lower probability for infection.

Overview of the Epidemiological Profileand Laboratory Detection of Extended-Spectrum β-Lactamases

Extended-spectrum beta-lactamases (ESBLs) are plasmid-mediated bacterial enzymes that confer resistance to a broad range of beta-lactams. They are descended by genetic mutation from native beta-lactamases found in gram-negative bacteria, especially infectious strains of Escherichia coli and Klebsiella species. Genetic sequence modifications have broadened the substrate specificity of the enzymes to include third-generation cephalosporins, such as ceftazidime. Because ESBL-producing strains are resistant to a wide variety of commonly used antimicrobials, their proliferation poses a serious global health concern that has complicated treatment strategies for a growing number of hospitalized patients. Another resistance mechanism, also common to Enterobacteriaceae, results from the overproduction of chromosomal or plasmid-derived AmpC beta-lactamases. These organisms share an antimicrobial resistance pattern similar to that of ESBL-producing organisms, with the prominent exception that, unlike most ESBLs, AmpC enzymes are not inhibited by clavulanate and similar beta-lactamase inhibitors. Recent technological improvements in testing and in the development of uniform standards for both ESBL detection and confirmatory testing promise to make accurate identification of ESBL-producing organisms more accessible to clinical laboratories.

Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017

Importance The human and financial costs of treating surgical site infections (SSIs) are increasing. The number of surgical procedures performed in the United States continues to rise, and surgical patients are initially seen with increasingly complex comorbidities. It is estimated that approximately half of SSIs are deemed preventable using evidence-based strategies. Objective To provide new and updated evidence-based recommendations for the prevention of SSI. Evidence Review A targeted systematic review of the literature was conducted in MEDLINE, EMBASE, CINAHL, and the Cochrane Library from 1998 through April 2014. A modified Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach was used to assess the quality of evidence and the strength of the resulting recommendation and to provide explicit links between them. Of 5759 titles and abstracts screened, 896 underwent full-text review by 2 independent reviewers. After exclusions, 170 studies were extracted into evidence tables, appraised, and synthesized. Findings Before surgery, patients should shower or bathe (full body) with soap (antimicrobial or nonantimicrobial) or an antiseptic agent on at least the night before the operative day. Antimicrobial prophylaxis should be administered only when indicated based on published clinical practice guidelines and timed such that a bactericidal concentration of the agents is established in the serum and tissues when the incision is made. In cesarean section procedures, antimicrobial prophylaxis should be administered before skin incision. Skin preparation in the operating room should be performed using an alcohol-based agent unless contraindicated. For clean and clean-contaminated procedures, additional prophylactic antimicrobial agent doses should not be administered after the surgical incision is closed in the operating room, even in the presence of a drain. Topical antimicrobial agents should not be applied to the surgical incision. During surgery, glycemic control should be implemented using blood glucose target levels less than 200 mg/dL, and normothermia should be maintained in all patients. Increased fraction of inspired oxygen should be administered during surgery and after extubation in the immediate postoperative period for patients with normal pulmonary function undergoing general anesthesia with endotracheal intubation. Transfusion of blood products should not be withheld from surgical patients as a means to prevent SSI. Conclusions and Relevance This guideline is intended to provide new and updated evidence-based recommendations for the prevention of SSI and should be incorporated into comprehensive surgical quality improvement programs to improve patient safety.

Prolonged Suppressive Antibiotic Therapy for Infected Orthopedic Prostheses

Prolonged suppressive antibiotic therapy may be an alternative to removal of infected orthopedic prostheses in some patients. However, the efficacy of prolonged suppressive antibiotics is not well established. We retrospectively reviewed 18 patients with infected orthopedic prostheses who had been treated with prolonged antimicrobial suppression during the last 10 years. Eighteen episodes of infection were identified in these 18 patients. There were nine men and nine women, and the mean age was 66 years (range, 31-83 years). All patients had a functional prosthesis and were treated with surgical debridement, retention of the prosthesis, and administration of intravenous antibiotics for 6-8 weeks, followed by prolonged oral antibiotic suppression. Fifteen of the 18 patients appear to have had a good response and have been able to retain a functional prosthesis. Complications related to antibiotic suppression occurred in 22% but did not necessitate discontinuation of the antibiotic therapy. Prolonged antibiotic suppression is a reasonable alternative to surgery in selected patients with infected orthopedic prostheses.

American Academy of Orthopaedic Surgeons clinical practice guideline on: the diagnosis of periprosthetic joint infections of the hip and knee.

AAOS Guideline on The Diagnosis of Periprosthetic Joint Infections of the Hip and Knee Summary of Recommendations The following is a summary of the recommendations in the AAOS’ clinical practice guideline, The Diagnosis of Periprosthetic Joint Infections of the Hip and Knee. This summary does not contain rationales that explain how and why these recommendations were developed nor does it contain the evidence supporting these recommendations. All readers of this summary are strongly encouraged to consult the full guideline and evidence report for this information. We are confident that those who read the full guideline and evidence report will note that the recommendations were developed using systematic evidence-based processes designed to combat bias, enhance transparency, and promote reproducibility. This summary of recommendations is not intended to stand alone. Clinical decisions should be made in light of all circumstances presented by the patient. Procedures applicable to the individual patient rely on mutual communication between patient, physician, and other healthcare practitioners. 1. In the absence of reliable evidence about risk stratification of patients with a potential periprosthetic joint infection, it is the opinion of the work group that testing strategies be planned …

High-dose daptomycin for treatment of complicated gram-positive infections: A large, multicenter, retrospective study

Study Objective. To evaluate the clinical response and safety of high‐dose daptomycin for treatment of complicated gram‐positive infections.

Health Care—Associated Pneumonia (HCAP): A Critical Appraisal to Improve Identification, Management, and Outcomes—Proceedings of the HCAP Summit

Increasingly, patients are receiving treatment at facilities other than hospitals, including long-term-health care facilities, assisted-living environments, rehabilitation facilities, and dialysis centers. As with hospital environments, nonhospital settings present their own unique risks of pneumonia. Traditionally, pneumonia in these facilities has been categorized as community-acquired pneumonia (CAP). However, the new designation for pneumonias acquired in these settings is health care-associated pneumonia (HCAP), which covers pneumonias acquired in health care environments outside of the traditional hospital setting and excludes hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and CAP. Although HCAP is currently treated with the same protocols as CAP, recent evidence indicates that HCAP differs from CAP with respect to pathogens and prognosis and, in fact, more closely resembles HAP and VAP. The HCAP Summit convened national infectious disease opinion leaders for the purpose of analyzing current literature, clinical trial data, diagnostic considerations, therapeutic options, and treatment guidelines related to HCAP. After an in-depth analysis of these areas, the infectious disease investigators participating in the summit were surveyed with regard to 10 clinical practice statements. The results were then compared with results of the same survey as completed by 744 Infectious Diseases Society of America members. The similarities and differences between those survey results are the basis of this publication.

Daptomycin for the Treatment of Gram‐Positive Bacteremia and Infective Endocarditis: A Retrospective Case Series of 31 Patients

Study Objective. To evaluate the outcomes in patients with bacteremia and/or infective endocarditis who were treated with daptomycin.

Use of daptomycin to treat drug-resistant Gram-positive bone and joint infections

ABSTRACT Objective: Drug-resistant, Gram-positive bacteria are a growing concern in treating bone and joint infections, including osteomyelitis. This report describes the experience in a series of cases of the use of a novel antibiotic, daptomycin, for the treatment of bone and joint infections. Research design and methods: This retrospective analysis included patients from two medical centers diagnosed with Gram-positive bone and joint infections and treated with daptomycin. Results: A total of 10 patients were included in this report, of which nine received previous antibiotic therapy, including vancomycin, linezolid, and quinupristin/dalfopristin. Methicillin-resistant Staphylococcus aureus was isolated from eight patients while the remaining patients were infected with enterococci or streptococci. All patients initially resolved the infection while undergoing daptomycin treatment and were discharged from the hospital. One patient was switched to ampicillin (after receiving daptomycin for 4 days) once the infection was identified due to vancomycin-susceptible enterococcus. However, one patient was readmitted after 18 days due to a clinical relapse, possibly caused by under-dosing of daptomycin. Conclusion: Eight out of nine patients who received daptomycin for at least 8 days were successfully treated with the agent for Gram-positive bone and joint infections. Daptomycin was found to be well tolerated, even up to 44 days of treatment.

Outbreak of Adenovirus Genome Type 7d2 Infection in a Pediatric Chronic-Care Facility and Tertiary-Care Hospital

An outbreak of adenovirus infection that involved residents of a pediatric chronic-care facility, staff of a tertiary-care hospital, and a nosocomial hospital case was studied. In the pediatric facility, 31 (33%) of 93 residents had adenovirus infection, and 8 died. Risk factors for illness were an age of < 7 years (P = .004), presence of a tracheostomy (P = .015), and residence on a particular floor (P < .001). In the tertiary-care hospital, 36 health care workers had adenovirus infection; 26 (72%) had failed to follow strict contact and droplet precautions, and 30 (83%) continued to care for patients while they had symptoms. A 5-month-old patient with underlying lung disease acquired severe adenovirus infection in this hospital. All isolates were adenovirus type 7 (Ad7). DNA restriction analysis revealed the band patterns of all isolates to be identical and characteristic of the genome type d2. Thus, Ad7d2 caused significant morbidity and mortality in persons in the pediatric chronic-care facility and tertiary-care hospital. This is the first published description of Ad7d2 strains in the United States.