Luca Lazzarini

Osteomyelitis in Long Bones

Osteomyelitis in long bones remains challenging and expensive to treat, despite advances in antibiotics and new operative techniques. Plain radiographs still provide the best screening for acute and chronic osteomyelitis. Other imaging techniques may be used to determine diagnosis and aid in treatment decisions. The decision to use oral or parenteral antibiotics should be based on results regarding microorganism sensitivity, patient compliance, infectious disease consultation, and the surgeons experience. A suppressive antibiotic regimen should be directed by the results of cultures. Standard operative treatment is not feasible for all patients because of the functional impairment caused by the disease, the reconstructive operations, and the metabolic consequences of an aggressive therapy regimen. Operative treatment includes debridement, obliteration of dead space, restoration of blood supply, adequate soft-tissue coverage, stabilization, and reconstruction.

Cryptococcal Meningitis and Intracranial Tuberculoma in a Patient with Waldenstrom's Macroglobulinemia Treated with Fludarabine

We report a patient with Waldenstroms Macroglobulinemia who presented with cryptococcal meningitis followed by an intracranial tuberculoma during the 18 months period after termination of cytotoxic therapy with Fludarabine. Opportunistic infections due to intracellular organisms are extremely rare in the course of this malignancy and we review the predisposing factors of these infectious entities.

Postoperative Infections Following Total Knee Replacement: An Epidemiological Study

Abstract From January 1991 to June 1997 217 patients undergoing monolateral or bilateral total knee replacement (TKR) were consecutively enrolled in a prospective study on the incidence of postoperative infections and related risk factors. Regional antimicrobial prophylaxis (teicoplanin 400 mg) was used in 263 (95%) prostheses implanted; in the remaining 14 implants (5%) periopera-tive antibiotic prophylaxis (teicoplanin 800 mg) was administered as usual by systemic route. None of the patients experienced local or systemic adverse effects. Over the 2-year follow-up period, 8 (2.9%) primary site infectious complications were recorded, i.e. 4 superficial infections, which were cured without involvement of the prostheses, and 4 deep infections, which required prosthesis removal. Six infections occurred in patients who had undergone previous surgery of the same knee joint, and 2 in patients undergoing primary TKR (p=0.0005); diabetic patients had infections (13%) more frequently than non-diabetic patients (1.9%, p=0.01). Staphylococci were the leading organisms isolated from infections; however 3 strains of Escherichia coli were isolated from patients who had undergone a previous prosthesis implantation at the same knee joint. Regional administration of teicoplanin appears to be a safe and valuable prophylactic technique; however, in patients at risk of infection a prophylactic regimen which is also active against Gram-negative bacteria should probably be considered.

Mycobacterium tuberculosis and Mycobacterium fortuitum Osteomyelitis of the Foot and Septic Arthritis of the Ankle in an Immunocompetent Patient

Abstract.Mycobacteria, both tuberculous and nontuberculous, are recognized as a cause of chronic bone and joint infection. However, the diagnosis of mycobacterial infection is easily missed because of the absence of systemic involvement. Moreover, specific microbiologic techniques are required to detect mycobacteria in clinical specimens. Infections due to uncommon pathogens such as mycobacteria are more likely to occur in the immunocompromised host. A case of septic arthritis of the ankle and osteomyelitis of the foot due to both tuberculous and nontuberculous mycobacteria in an immunocompetent host is reported here.

Three-Times Weekly Teicoplanin in the Outpatient Treatment of Acute Methicillin-Resistant Staphylococcal Osteomyelitis: A Pilot Study

Abstract Treatment of osteomyelitis requires prolonged hospital stay, lengthy antibiotic therapy and adequate surgical debridement. Outpatient parenteral antibiotic therapy (OPAT) is a new approach to reduce patient discomfort and hospital costs. Teicoplanin, a glycopeptide antibiotic with a long half-life (72 hours), is one of the most useful drugs for OPAT. We performed a pilot study to assess the safety and efficacy of three-times weekly teicoplanin in the treatment of methicillin-resistant (MR) acute staphylococcal osteomyelitis. Ten patients with acute post-traumatic osteomyelitis were enrolled. Pathogens were MR Staphylococcus aureus (5 patients) and MR coagulase-negative staphylococci (5 patients). After a loading dose of 400 mg b.i.d. for 3 days, patients were treated with an intravenous dose of 1000 mg on Mondays and Wednesdays and with a 1200 mg dose on Fridays. Teicoplanin trough levels were maintained within a 10 to 20 mg/L range. If hardware removal had been possible at enrollment, treatment was carried out for at least 4 weeks. If, on the contrary, hardware removal had not been possible, teicoplanin was administered as sup-pressive therapy until hardware removal. Treatment was successfully performed in 9 out of 10 patients, whereas in one patient only improvement was achieved. Side effects were not recorded. Three times weekly teicoplanin seems to be a valuable option in the treatment of acute MR staphylococcal osteomyelitis. Further studies are warranted in order to better define the role of this new administration schedule in this field.

Clostridial Orthopedic Infections: Case Reports and Review of the Literature

Abstract Clostridia are anaerobic Gram-positive bacilli that can be isolated from the soil and the intestinal tract of humans. These microorganisms are recognized as the cause of devastating soft tissue infections, such as cellulitis, myositis, and gas gangrene. However, such bacteria may also be involved in various postoperative orthopedic infections, including prosthetic joint infection. We present three clinical cases of clostridial orthopedic infection and review the related medical literature.

Clinical Features of Bacterial Meningitis in Italy: a Multicenter Prospective Observational Study

Abstract We carried out a prospective observational study on clinical features of bacterial meningitis. Between October 2002 and June 2005, 322 adult bacterial meningitis cases in 49 infectious disease wards in Italy (MENTORE study group) were enrolled in the study. 133 cases were due to Streptococcus pneumoniae, 44 to Neisseria meningitides and 145 to other microorganisms. A high SAPS score and coma on admission, as well as need for mechanical ventilation, were more frequent in the pneumococcal meningitis group. Neurological impairment was present in 151 out of 311 patients, and was more frequent in pneumococcal meningitis. A single antibiotic was employed in only 90 of 315 cases; a combination of ceftriaxone and ampicillin was the most frequently administered treatment. Ceftriaxone was also the single most used drug. Adjunctive treatment with steroids was administered in 210 out of 303 patients for a median duration of 7 days. Median duration of fever was 4 days, and median hospital stay was 16 days; hospitalization was significantly longer in the pneumococcal meningitis group. At discharge, neurological impairment was still present in 59 (21%) of 277 patients. Twenty (6.9%) out of 289 patients died during hospitalization. Distribution of adverse outcome (death and neurological impairment) in patients treated with or without steroids and within different time zones between onset of symptoms and commencement of antibiotics was studied; a trend toward a worse prognosis was seen in patients treated more than 24 hours after onset of the disease. In our study, infectious disease clinicians made extensive use of steroids as adjuvant therapy for bacterial meningitis, even in absence of detailed national and local guidelines. Mortality seemed to be lower in comparison with the literature.

Removal of Central Venous Catheters from Patients with Candidemia

Sir—We read with interest the recent article “Should Vascular Catheters Be Removed from All Patients with Candidemia? An Evidence-Based Review” by Nucci and Anaissie [1], who attempt to clarify a controversial issue related to the clinical management of this infection. As the authors of a study [2] cited in their article, we were surprised by the interpretation of some of our data, and we would like to add our comments on this topic. First, in our retrospective study [2], removal of central venous catheters (CVCs) was associated with a significant decrease in the mortality rate (OR, 0.62; 95% CI, 0.38–0.99; ). The mortality rate P p .047

Failure of Intravenous Linezolid to Treat Clostridium difficile Associated Diarrhea

Linezolid, a new oxazolidinone drug, is currently used in the treatment of Gram-positive infections, including infections due to methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus faecalis, and penicillin-resistant Streptococcus pneumoniae 1. Furthermore, this drug possesses in vitro inhibitory activity against a broad range of Gram-positive bacteria, including anaerobic cocci 2. A bactericidal effect of linezolid against Clostridium perfringens and Clostridium difficile has been documented 3. The latter microorganism is the major cause of nosocomial diarrhea and antimicrobial associated colitis. Since few antimicrobials are effective in the treatment of these infections, there is a great deal of interest on the possible clinical use of new antibiotics. We describe the first case of failure of a linezolid treatment to cure a C. difficile related diarrhea. A 57-year-old female patient was admitted to our department complaining of fever, abdominal pain, and diarrhea. She had been treated with chemotherapy for a myeloblastic acute leukemia until 10 days before admission. A week before admission, the patient was also treated with oral ciprofloxacin for 3 days because of a transient episode of fever. In the hematology outpatient service, a stool culture for evidence of vancomycin-resistant Enterococcus faecium was obtained 3 days before admission, according to a local protocol of epidemiological surveillance, and was positive. The clinical examination showed a painful and tender abdomen and mild signs of dehydration. The patient’s white blood cell count was 23,000/mm3, erythrocyte sedimentation rate was 82, and C-reactive protein was 11.2 U\L. Journal of Chemotherapy Vol. 15 n. 3 (299-300) 2003

The application of cost effectiveness analysis to derive a formulary for urinary tract infections.

Abstract According to economic principles an inappropriate prescription is the choice of an antimicrobial with higher/equivalent cost and lower effectiveness (or higher cost and equivalent/lower efficacy) than an alternative (in this case, the former is specified as a “dominated” drug). To identify cost-effective antibiotics we applied the principles of incremental cost-effectiveness analysis (ICEA) to microbiological data of San Bortolo Hospital. Its 27 wards were grouped in 9 functional areas. The resistance patterns of 8 urinary pathogens in the 1997 microbiology data base were assessed. The measure of antibiotic effectiveness was expressed as the percentage of isolates susceptible to each antibiotic tested. The difference in cost (i.e. the incremental change) between each antibiotic and the next more expensive alternative was calculated, and compared with the incremental change in effectiveness. Calculations were made for each pathogen. The antibiotics remaining after exclusion of all “dominated” antibiotics were pooled on a list defined as “Specific Area Formulary”. The implications of the use of economic principles within a general antimicrobial policy are discussed.