Tiziana Ascione

Sonication of antibiotic-loaded cement spacers in a two-stage revision protocol for infected joint arthroplasty

BackgroundCulturing of the sonication fluid of removed implants has proven to be more sensitive than conventional periprosthetic tissue culture for the microbiological diagnosis of prosthetic joint infection. Since bacteria surviving on antibiotic-loaded cement spacers used in a two-stage exchange protocol for infected arthroplasties may cause the persistence of infection, in this study we asked whether the sonication also could be used to identify bacteria on antibiotic-loaded cement spacers removed at the second surgical stage during a two-stage exchange procedure to confirm whether or not the prosthetic joint infection had been eradicated.MethodsWe cultured the sonication fluid of cement spacers that had been originally implanted in a two-stage exchange protocol in 21 patients (mean age, 66xa0years) affected by prosthetic joint infection (16 total knee prostheses and 5 hip prostheses). The cement spacers were vortexed for 30xa0seconds and then subjected to sonication (frequency 35–40 KHz). The resulting sonicate fluid was cultured for aerobic and anaerobic bacteria.ResultsThe sonication fluid culture of the removed spacer was positive in six patients (29%), with isolation of methicillin-sensible Staphylococcus Aureus (MSSA) in three cases, methicillin-resistant Staphylococcus Aureus (MRSA) in one case and Pseudomonas Aeruginosa in two cases. In three of these positive cases, the traditional culture of periprosthetic tissue was negative. Two patients with positive sonication culture of the spacer were successfully treated by early debridement of the revision prosthesis and systemic antibiotic therapy. In three patients a knee arthrodesis was planned and performed as the second surgical stage. In two of them the infection was caused by highly resistant Pseudomonas Aeruginosa. The other patient with a MSSA infection had been poorly compliant with the systemic antibiotic therapy due to her mental impairment. The patient originally affected by MRSA infection of his primary hip arthroplasty developed recurrent infection of his revision prosthesis and eventually underwent Girdlestone arthroplasty.ConclusionsThe sonication culture can be used to discover any bacteria on the antibiotic-loaded cement spacer during a two-stage exchange protocol, thus permitting the adoption of timely treatment options, such as the early prosthetic debridment.

Visceral leishmaniasis causes fever and decompensation in patients with cirrhosis

Infections and fever due to bacterial infections are well-known complications of liver cirrhosis, and often trigger decompensation and death.1 Visceral leishmaniasis (VL), a protozoan infection endemic in the Mediterranean area, causes a febrile disease, the clinical and laboratory features (splenomegaly, pancytopenia, reduced serum albumin and increased γ-globulin concentrations) of which largely overlap with those of cirrhosis.2,3 Although the areas where VL is endemic coincide with areas where the prevalence of cirrhosis is high, no study has described VL in patients with cirrhosis.nnDuring a 12-year period, all patients with cirrhosis admitted for decompensation and fever lasting more than 1 week, unresponsive to broad-spectrum antibiotics, underwent diagnostic procedures for VL. For each case diagnosed as VL, three consecutive cases of bacterial infection observed in the same period were enrolled. Cirrhosis was defined …

Clinical Efficacy and Tolerability of Levofloxacin in Patients with Liver Disease: A Prospective, Non Comparative, Observational Study

Abstract The aim of this open, non comparative, observational study was to assess the clinical and bacteriological efficacy, the tolerability and safety of levofloxacin for treatment of concurrent bacterial infections in patients with chronic liver disease. Overall, 40 patients (inpatients or outpatients) were recruited to the study (28 with UTI, 6 with pneumonia, and 6 with spontaneous bacterial peritonitis (SBP)). Patients affected by UTI received 250 mg oral levofloxacin once daily for five days; patients with pneumonia or SBP underwent a 10/14-day therapeutic oral regimen with 500 mg b.i.d. Clinical evaluation and possible side effects were monitored daily both in out- and in-patients. For all patients, laboratory tests were performed at baseline and 3-4 days after the end of therapy in order to evaluate levofloxacin tolerability. Statistical analysis was performed by means of Students t test to show differences between cases; all values are reported as means and standard deviations and p values were considered as significant when p<0.05. After treatment, clinical cure and bacteriological eradication were achieved in all patients (40/40; 100%). Adverse events, mainly gastrointestinal disturbances (e.g. nausea), were observed in 5 out of 40 patients (12.5%) and no neurotoxic effects were registered (e.g. anxiety, hallucinations, convulsions, mental confusion). No significant variation in laboratory tests due to hematic crasis and/or hepatic and renal disorders was observed. Levofloxacin proved to be highly efficacious and safe in the treatment of bacterial infections in patients affected by liver disease.

Pneumococcal meningitis in cirrhotics: Distinctive findings of presentation and outcome

Kang et al. recently reported an increased mortality after bacteraemia in patients with liver cirrhosis. Although Streptococcus pneumoniae is a well known cause of invasive infection, particularly in immunodepressed patients such as those living with cirrhosis, the authors do not report any case of pneumococcal meningitis and the study cannot establish the distinctive findings of this important invasive infection in cirrhotics. In a prospective study of adult patients with pneumococcal meningitis referred during a fourteen-year period to our Department of Infectious Diseases, we reviewed the characteristics of the case observed in cirrhotics in respect to the whole population of patients with pneumococcal meningitis. Diagnosis of pneumococcal meningitis had to be based on characteristic clinical signs and symptoms (i.e. fever, nuchal rigidity, impaired consciousness), on CSF or blood cultures yielding S. pneumoniae and on cerebro-spinal fluid (CSF) pleocytosis. The diagnosis of cirrhosis had to be documented by liver histology or unequivocal clinical, laboratory, ultrasonographic (US) and endoscopic findings. The inclusion criteria were: i) diagnosis of pneumococcal meningitis established by positive cultures and CSF pleocytosis; ii) age > 18 years; iii) post-therapy follow-up of at least 8 weeks for surviving cases. The exclusion criteria were: i) co-infection with HIV; ii) negative blood and CSF cultures. Two-hundred-and-fifteen patients were enrolled in the study. Liver cirrhosis was diagnosed in 21 cases (10%); median age was 57 years [Interquartile Range (IQR) 38e65], respectively, 61 years (IQR 53e68) in cirrhotics and 56 years (IQR 38e65) in non-cirrhotics. Cirrhosis aetiology was viral in all cases (15 HCV, 6 HBV) and alcohol was a co-factor in 2 cases. Median MELD score was 10 (IQR 8e14). Median CTP score was 7 (IQR 6e9). Median (IQR) duration of general symptoms (fever, headache and vomiting) prior to admission due to neurological evidence was 54 (18e76) hours for non-cirrhotics and 24 (12e30) hours for cirrhotics (p Z 0.004). A significantly lower proportion of cirrhotics presented with fever at admission (16/21 vs 185/194, c Z 8.51, p Z 0.006, Odds ratio 0.16, 95% C.I. 0.04e0.67). A higher proportion of cirrhotics presented without nuchal rigidity (10/21 vs 44/194, c Z 5.01, p Z 0.025, Odds ratio 3.10, 95% C.I. 1.13e8.50). No predisposing factors, defined as infective foci outside the central nervous system (pneumonia, otitis media or sinus infection) or evidence of basal leak, were reported in 66 (31%) cases. The proportion of cases without predisposing conditions was higher among cirrhotics (12/21 vs 54/194, c Z 6.34, p Z 0.012, Odds ratio 3.46, 95% C.I. 1.27e9.53). Haematological findings showed lower counts of white blood cells (WBC), neutrophils and platelets in cirrhotics. No significant difference in the results of CSF analysis performed at admission was found (Table 1). One-hundred-and-fifty-seven (73%) cases were infected by pneumococcal strains susceptible to penicillin, 19 (9%) by penicillin-resistant pneumococcal strains (Minimal Inhibitor Concentration [MIC] 2 mg/ml), and 39 (18%) by pneumococcal strains with intermediate resistance (MIC 0.1 1 mg/ml) to penicillin. The proportion of cases with reduced susceptibility to penicillin (MIC 0.1 mg/ml) was higher in cirrhotics (10/21 vs 48/194, c Z 3.94, p Z 0.047, Odds ratio 2.77, 95% C.I. 1.01e7.55). A favourable outcome was reported in 124 cases (58%), 26 patients had sequelae and 65 died. The mortality rate

Oral Therapy, Microbiological Findings, and Comorbidity Influence the Outcome of Prosthetic Joint Infections Undergoing 2-Stage Exchange

BACKGROUNDnThe aim of the present study was to investigate potential predictive factors of an unfavorable outcome in patients with prosthetic joint infection (PJI) undergoing 2-stage exchange.nnnMETHODSnPatients with PJI undergoing 2-stage exchange and observed over a 5-year period (2009-2013) were included. Cure was defined by the disappearance of infection after a 96-week follow-up period. Statistical analysis was performed using the Mann-Whitney U test, the Fisher exact test, and the multivariate analysis.nnnRESULTSnOne-hundred twenty-two patients with PJI were included (median age, 69 years [range, 36-80 years]; 48% males, 47 hip PJI, and 75 knee PJI). Known comorbidities related to an increased risk of infection were reported in 43 patients (35%). Microbiological definition was obtained in 101 (83%) patients, and Staphylococcus aureus was isolated in 44 (36%) patients. Coagulase-negative staphylococci were isolated in 41 (34%) patients. A favorable outcome was obtained in 102 of 122 patients (84%). After univariate analysis, bacterial growth from operative specimens (Pxa0= .007), growth of Gram-positive bacteria (P < .001), use of oral therapy (Pxa0= .01), and absence of known comorbidities (Pxa0= .02) were associated with favorable outcome. Administration of rifampin (Pxa0= .99) and results of blood analysis were not predictive of outcome. After multivariate analysis was applied, infection sustained by Gram-positive bacteria, administration of oral antibiotics, and absence of known comorbidities frequently resulted in favorable outcome.nnnCONCLUSIONnA favorable outcome in patients with PJI undergoing 2-stage procedure was associated with an infection sustained by Gram-positive bacteria, absence of known comorbidities, and administration of oral therapy. Therefore, failure rate can be reduced with appropriate treatment choices.

Deep tissue biopsy vs. superficial swab culture, including microbial loading determination, in the microbiological assessment of Skin and Soft Tissue Infections (SSTIs)

Thirty-two patients affected by SSTIs including DFIs were enrolled between 2013 and 2014. Superficial swab was obtained before and after cleansing with sterile saline, and after ultrasonic debridement; deep tissue biopsy was obtained from ulcer base. Samples were diluted with 1 mL of saline, serial 10-fold dilutions to 10−6 were made and 50 μL of each dilution was plated onto appropriate media. Bacteria were identified by Vitek II system. Microbial load was expressed as CFU/mL. Statistical analysis was performed by χ2. Incidence of Gram positives was higher than Gram negatives (S. aureus and P. aeruginosa being the most frequent); concordance (same bacteria isolated before and after debridement) never exceeded 60%. Ultrasonic debridement significantly reduced bacterial load or even suppressed bacterial growth. While reliability of superficial swab is poor for microbiological diagnosis of SSTIs, swabbing after ultrasonic debridement and biopsy of the ulcer base may be equally reliable.

ITPase activity modulates the severity of anaemia in HCV-related cirrhosis treated with ribavirin-containing interferon-free regimens

BACKGROUNDnTo investigate the association between inosine triphosphatase (ITPase) activity and the degree of anaemia occurring during direct-acting antiviral (DAA)/ribavirin (RBV)-based therapy in patients with cirrhosis.nnnMETHODSnIn a multicentre, prospective study 227 patients with HCV-related cirrhosis treated with DAA and RBV were enrolled. All patients were screened for the rs1127354 and rs7270101 ITPA single nucleotide polymorphisms using direct sequencing.nnnRESULTSn150 (66.1%) patients had normal (100%) ITPase activity, 48 (21.1%) had moderate (60%) activity and 29 (12.8%) minimal (≤30%) activity. The ITPase activity significantly influenced the haemoglobin concentration: at day 15 it was -1.248 (sd ±0.978) in the 150 patients with an ITPase activity of 100% and -0.616 (±0.862) in the 77 patients with an ITPase activity less than 100% (P<0.000), and at day 30 it was -1.941 ±1.218 versus -1.11 ±1.218 (P<0.000). The 63 patients with a severe (at least 3/dl) haemoglobin decline, compared to those without, more frequently had an ITPase activity of 100% (82.1% versus 62.8%; P=0.021), were older (mean age ±sd: 66.7 ±8.2 versus 61.4 ±9.7 years; P=0.004) and were treated with a higher ribavirin dose (13.7 ±2.1 versus 12.8 ±2.5 mg/kg/day; P=0.008). At multivariate logistic regression analysis, the ITPase activity of 100% (OR: 2.83; 95% CI: 1.12, 7.10), male gender (OR: 3.22; 95% CI: 1.35, 7.66), body mass index (OR: 1.17; 95% CI: 1.03, 1.34) and dose of ribavirin (OR: 1.22; 95% CI: 1.06, 1.47) were independent predictors of a severe decline in haemoglobin (P<0.0001).nnnCONCLUSIONSnThis study suggests that the polymorphisms in the ITPA gene influence the severity of anaemia during the first month of a DAA/RBV-based treatment in HCV-related cirrhosis.

Diagnostic accuracy of synovial fluid, blood markers, and microbiological testing in chronic knee prosthetic infections

IntroductionThis retrospective study was undertaken to define cut-off values for synovial fluid (SF) leukocyte count and neutrophil percentage for differentiating aseptic failure and periprosthetic joint infection (PJI) and to evaluate the diagnostic accuracy of blood inflammatory markers, and microbiological testing according to the criteria proposed by the International Consensus Meeting (ICM) of Philadelphia.MethodsAll patients who underwent revision total knee arthroplasty from January 2010 to July 2015 were included: we identified and classified 31 PJIs and 136 aseptic joints. The diagnostic performance of single test was assessed by receiver operating characteristic curve analyses. The sensitivity and specificity were calculated for each of the cut-off values and the area under the curve (AUC) was calculated.ResultsThe median SF leukocyte count as well as the neutrophil percentage and inflammatory markers were significantly higher in patients with PJI than in those with aseptic failure (pxa0<xa00.001). A leukocyte count ofxa0>xa02.8xa0×xa0103/μL had a sensitivity of 83.8% and a specificity of 89.7% whereas a neutrophil percentage ofxa0>xa072% yielded a marginally higher sensitivity of 84% and a specificity of 91%. Applying the ICM criteria we found a significant correlation between all these diagnostic measures and PJI (pxa0<xa00.001) except for a single positive culture. The most accurate criterion of the ICM was the synovial neutrophil differential (AUCxa0=xa00.89; 95% CI 0.81–0.97), followed by SF leukocyte count (AUCxa0=xa00.86; 95% CI 0.78–0.94), increased inflammatory markers (AUCxa0=xa00.85; 95% CI 0.76–0.93), and two positive periprosthetic cultures (AUCxa0=xa00.84; 95% CI 0.73–0.94). The presence of sinus tract communicating with the joint and a single positive culture showed unfavourable diagnostic accuracy (AUCxa0=xa00.60, 95% CI 0.47–0.72; AUCxa0=xa00.49, 95% CI 0.38–0.61, respectively)ConclusionsThe present study highlights the adequate ability of fluid cell count and neutrophil differential to distinguish between PJI and aseptic loosening. The clinical utility of fluid analysis in diagnosing infection can be improved by evaluation of other diagnostic criteria.Level of evidenceLevel I Diagnostic Study.

Knee Septic Arthritis after Arthroscopy: Incidence, Risk Factors, Functional Outcome, and Infection Eradication Rate

Purpose u2003Septic knee arthritis following arthroscopy is a rare but dreaded complication. Definition and management of knee deep infections are quite discussed in literature. In this review, literature regarding infections after knee arthroscopy is analyzed highlighting the incidence, causative bacteria, risk factors as well as clinical outcomes. Methods u2003We performed a review of the literature matching the following key words: “septic arthritis” OR “infection” AND “arthroscopy” AND “knee.” Knee arthroscopic procedures, such as debridement, meniscectomy, meniscus repair, synovectomy, microfracture, and lateral release, were considered. Complex procedures, such as ligament reconstruction, fractures, or complex cartilage repair techniques, were not included. Results u2003Thirteen studies were included in this review. Incidence of infection ranged from 0.009 to 1.1% in patients undergoing simple arthroscopic procedures. Staphylococci are the most commonly isolated organisms from postarthroscopy infection. Use of intraoperative intra-articular steroids, smoking, obesity, male sex, diabetes, number of procedures performed during surgery, time of surgery, and tourniquet time of more than 60 minutes have been certified as risk factors for knee infection. Conclusion u2003Postarthroscopy septic arthritis of the knee causes significant morbidity, usually requiring readmission to the hospital, at least one additional operation, and prolonged antibiotic therapy, both intravenous and oral. Prompt diagnosis and treatment are associated with a high success rate. Level of Evidence u2003Level IV, systematic review of I-IV studies.

Clinical and microbiological outcomes in haematogenous spondylodiscitis treated conservatively

IntroductionSpondylodiscitis refers to infections of the intervertebral disc and the adjacent vertebral body. Although it is still considered a rare condition, its rate is projected to increase. Mortality rate is considered to be low, but an estimated one third of the survivors experience residual disabilities. Literature shows that uncomplicated spondylodiscitis can be adequately treated by early antibiotic therapy and immobilization. The aim of the study is to evaluate the outcome of conservative treatment in patients with haematogenous spondylodiscitis.Materials and methodsAll patients with haematogenous spondylodiscitis observed in two orthopaedic centres were retrospectively considered. The medical records, radiologic imaging, bacteriology results, treatment, and complications of all patients were reviewed.ResultsThirty patients (median age 64xa0years, range 15–77, females 56.7%) were considered in the study, eight (26.7%) showed residual back pain at median follow-up of 117xa0weeks (range 104–189). A significant difference in SF-36 physical (Pxa0<xa00.001), SF-36 mental function (Pxa0<xa00.002), and Oswestry Disability Index (ODI) (Pxa0<xa00.001) scores was observed among patients with residual local pain compared to the ones who had not. Methicillin-resistant Staphylococcus aureus (MRSA) infection and symptoms duration before the diagnosis were associated with an increased risk of persistent back pain and permanent disability. The most important negative determinants of SF-36 mental function were the age of patients (ρxa0=xa00.36, Pxa0<xa00.05), the duration of symptoms before the diagnosis (ρxa0=xa00.44, Pxa0<xa00.05) and MRSA infection (Pxa0=xa00.006). Spondylodiscitis sustained by MRSA and the duration of symptoms before the diagnosis influenced negatively the physical status (Pxa0=xa00.002) and ODI (ρxa0=xa00.36, Pxa0<xa00.05), respectively.ConclusionsConservative approaches are safe and effective for patients without complications. A delayed diagnosis and MRSA infections are related to poor clinical outcome among patients treated by conservative treatment; this must be carried out scrupulously with close patient monitoring.