IL-1ß Promotes Staphylococcus aureus Biofilms on Implants in vivo.

Implant associated infections represent a serious health burden in clinics since some microorganisms are able to colonize biological surfaces or surfaces of indwelling medical devices and form biofilms. Biofilms represent communities of microorganisms attached to hydrated surfaces and enclosed in self-produced extracellular matrix. This renders them resistant to exogenous assaults like antibiotics or immune effector mechanisms. Little is known regarding the role of the immune system in the formation of biofilms during implant associated infections, largely due to the lack of suitable mouse models. Here we use colonized osmotic pumps in mice to study the interaction of an activated immune system with biofilm-forming Staphylococcus aureus encoding Gaussia luciferase. This approach permits biofilm formation on the osmotic pumps in living animals. It also allows the continuous supply of soluble immune cell activating agents, such as cytokines to study their effect on biofilm formation in vivo. Using non-invasive imaging of the bioluminescent signal emitted by the lux expressing bacteria for quantification of bacterial load in conjunction with light and electron microscopy, we observed that pump-supplied pro-inflammatory cytokine IL-1ß strongly increased biofilm formation along with a massive influx of neutrophils adjacent to the biofilm-coated pumps. Thus, our data demonstrate that immune defense mechanisms can augment biofilm formation.

Infections of Intrathecal Baclofen Delivery Systems and Ventriculoperitoneal Shunting Systems: Clinical Series Discussion.

BACKGROUND/AIMS: The physiological interaction between the intrathecal baclofen (ITB) delivery system and the ventriculoperitoneal (VP) shunting system in a patient who had both systems implanted has not been reported previously. The aim of our report is to evaluate the effect that one system's infection might have on the other. METHODS: Records of children who were followed at our institution between 2004 and 2015 for management of their ITB systems were reviewed. In this group, children who had VP shunts were identified, and those who had any of their ITB or VP systems infected were included. RESULTS: Out of 313 children managed with ITB therapy at our institution, 31 (24%) children had VP shunts. Two patients had infection in both systems, and 3 patients had infection in 1 system. CONCLUSION: This report suggests that if aspiration from both systems showed positive cultures, the treatment would be removal of both systems. If the primarily not infected system does not show positive cultures, it does not need to be removed. Close follow-up is recommended, and any sign of infection or malfunction of the primarily not infected device should be approached with a high level of suspicion.

Colonic perforation by an intrathecal baclofen pump catheter causing delayed Escherichia coli meningitis.

Intrathecal baclofen (ITB) delivery via an implanted pump is frequently used for the treatment of spasticity. This is an effective and safe neurosurgical and pharmacological intervention associated with an improvement in patient quality of life. There is, however, a risk of device-related infection. We present a patient with pump-site infection and Escherichia coli meningitis secondary to transcolonic perforation of an intrathecal baclofen pump catheter. While this is rare, we review the intraoperative precautions and best practices that should be taken to prevent and manage this unusual complication.

Could antibiotic prophylaxis be not necessary to implant totally implantable venous access devices? Randomized prospective study.

BACKGROUND: The growing use of totally implantable venous access devices (TIVAD) has caused the simultaneous increase of various complications. Among these, one of the most encountered is the infection of the subcutaneous pocket in which the device is positioned, or the infection of TIVAD itself. The aim of this study is to evaluate the role of the antibiotic in the prevention of the infection of both the surgical site and the TIVAD within 30 days after the implant. METHODS: The authors enrolled one hundred eight consecutive patients divided into two randomized arms each of 54 patients: group A (antibiotic), group B (no antibiotic). All patients were affected by solid tumors needing chemotherapy continuously. TIVADs were implanted surgically in cephalic vein. On the first, third, and seventh postoperative days, the following manifestations were considered as signs or symptoms of infection: pain, localized swelling, redness, and heat; white blood cell count was performed in the in-hospital laboratory. Body temperatures were checked twice a day for 7 days. A statistical analysis of the results was performed. RESULTS: No sign of infection was recorded in both groups. Body temperatures and white blood cell counts remained within normal limits in both groups. One month after the procedure no patients recorded any sign of skin infection or body temperature increase. CONCLUSIONS: The study suggests that, following strict methods of pre- and postoperative care, TIVADs in patients with solid tumors may be surgically implanted without any antibiotic prophylaxis.

In situ treatment of an infected intrathecal baclofen pump implant with gentamicin-impregnated collagen fleece.

Intrathecal delivery of baclofen using a subcutaneous pump is an effective long-term treatment for spasticity. Infections of the pocket, however, are often hard to eliminate with intravenous antibiotics. If a 2-stage procedure involving removal of the pump and baclofen withdrawal will create serious problems for the patient, infections can be treated with repetitive local application of gentamicin-impregnated collagen fleece.

Central venous access devices for paediatric patients with haemophilia: a single-institution experience.

Use of a central venous access device (CVAD) can facilitate early introduction of home-based infusion of factor concentrate for long-term prophylaxis or immune tolerance therapy in children with bleeding disorders. The aim was to review outcomes associated with use of CVAD. Retrospective review of paediatric patients with bleeding disorders was observed at the Mayo Clinic Comprehensive Hemophilia Center. Thirty-seven CVAD were placed in 18 patients (haemophilia A [n = 15], type 3 von Willebrand disease [n = 2] and haemophilia B [n = 1]). Follow-up was for 45 952 CVAD days, and median time that CVAD remained in place was 1361 days per device. Factor VIII (FVIII) inhibitors were present in 4 of the 15 patients. Ten CVAD-related infections occurred (median, 672 days; range, 72-1941 days), of which six were in one patient with FVIII inhibitors. Overall infection rate was 0.22 (95% confidence interval [CI], 0.10-0.40) per 1000 CVAD days, with 0.11 infections in patients without FVIII inhibitors compared with a pooled incidence of 0.66 (95% CI, 0.44-0.97) reported in the literature. Indications for removal of 27 CVAD were blockage, change to peripheral venous access, catheter displacement, infection, leak in the port septum, short catheter and skin erosion. No clinically apparent thrombosis or sequelae of thrombosis were observed. Infection is the most common complication associated with CVAD use and is increased in patients who have inhibitors. The low rate of clinically apparent thrombosis reflects our practice of not screening for thrombosis. The low infection rate reflects our practice of using and reinforcing the aseptic technique.

Prolonged, severe intrathecal baclofen withdrawal syndrome: a case report.

Intrathecal baclofen (ITB) withdrawal is a well-recognized complication when drug delivery is disrupted for any reason. ITB withdrawal varies widely in its severity and poses the very real possibility of death if not promptly managed. Cases of withdrawal lasting greater than 1 or 2 weeks, however, are sparse. We report the case of an 11-year-old girl with spastic quadriplegic cerebral palsy who developed an infected pump and subsequent meningitis, prompting the removal of her pump and catheter. She subsequently developed a severe, prolonged baclofen withdrawal syndrome marked by increased spasticity, agitation, hypertension, and tachycardia that lasted nearly 2 months, requiring intensive care and continuous intravenous sedation with benzodiazepines and opiates. Her pump was eventually replaced on hospital day 56 and within 24 hours her symptoms dramatically improved. She was eventually weaned off sedating medications and returned to baseline functional status. Typical management of baclofen withdrawal is reviewed. To date, the literature has not discussed the potential role for opiates in managing baclofen withdrawal, yet a growing body of literature is examining the interplay between opiates and gamma-aminobutyric acid B pathways. A potential role for opiates in managing severe baclofen withdrawal is proposed.

Introduction of infection control measures to reduce infection associated with implantable pain therapy devices.

INTRODUCTION: Implantable pain therapy devices for chronic pain include spinal cord stimulators (SCS) and intrathecal drug delivery systems (IDDS). A number of different complications can occur after implantation of these devices, but among the most serious is infection. Based on Centers for Disease Control and Prevention guidelines for prevention of surgical site infection, published literature on infection risk with implantable pain therapy devices, and recommendations from groups within our own our institution, we introduced infection control measures for all patients receiving either SCS or IDDS. METHODS: After approval from the Institutional Review Board, we performed a retrospective review of patients undergoing primary implantation of SCS or IDDS before and after introduction at our institution of safety measures designed to reduce device-related infection. We compared infection incidence and compliance to infection precautions before and after introduction of these measures. RESULTS: Thirty-four SCS or IDDS were implanted before implementation of the infection control measures and 58 were placed after. Five device-related infections occurred. Adherence to most infection precautions improved during the study period, but 100% compliance was seen only with venue used for implantation. Infection incidence declined after introduction of the safety measures, but the reduction was not statistically significant. CONCLUSIONS: Introduction of infection control measures for implantable pain therapy devices improved adherence to most infection precautions in our practice. Lack of specific documentation could have hindered practice surveillance within our group. A tool to document performance of infection control measures would be useful not only as a marker of compliance but could also serve as a reminder to perform certain safety measures.

Gram-negative meningitis and infections in individuals treated with intrathecal baclofen for spasticity: a retrospective study.

The aim of this retrospective study was to describe signs, symptoms, and clinical outcomes of individuals undergoing intrathecal baclofen (ITB) therapy who experienced pump-related Gram-negative infections including meningitis. Participants included 12 individuals (nine males, three females) aged 10 to 32 years (mean 17y 9mo), nine of whom had quadriplegic CP. A total of 571 baclofen pump surgeries were performed with 45 total infections. Of the 45 infections, 12 were by Gram-negative organisms, two resulting in meningitis. Ten of 12 Gram-negative infections (21 site encounters) occurred within 60 days of surgery. Eleven of 12 pumps were explanted. By site encounters, Pseudomonas aeruginosa accounted for eight Gram-negative infections, Escherichia coli for five, Proteus for three, Enterobacter cloacae for two, and Klebsiella, Enterobacter aerogenes, and Enterobacter vulnaris for one each. Two individuals with Gram-negative meningitis were admitted 72 to 96 hours after hospital discharge following pump replacement. Both patients had rapid deterioration requiring transfer to the pediatric intensive care unit, and developed coagulopathy and decrease in responsiveness. Both have improved and have elected not to replace the ITB pump. In Gram-negative infections in ITB therapy, the progression of signs and symptoms can be swift and devastating. Identification of the infectious agent in such cases is imperative; these infections can quickly become life threatening.

Implantable venous port-related infections in cancer patients.

OBJECTIVES: To evaluate the characteristics of implantable venous port-related infections in patients with malignancies. PATIENTS AND METHODS: This was a 6-year study in which all the records of cancer patients who were diagnosed with port-related infections were retrospectively analyzed. RESULTS: The analysis included 36 episodes of port-related infections. The median period from port implantation to the episode of port-related infection was 164 days (21 to 1650 days). Of the 36 episodes, 15 (42%) were polymicrobial infections, and 21 (58%) were gram-negative pathogens. If only the port-related bacteremia was taken into consideration, gram-negative bacilli and gram-positive cocci accounted for 39 and 7 pathogens of the total 53 isolated microorganisms (74% and 13%, respectively). Stenotrophomonas maltophilia and Acinetobacter baumanii were the predominant causal microorganisms. All except two infectious catheters were removed. No infection-related mortality developed. CONCLUSIONS: Gram-negative bacilli, especially the glucose-non-fermenting pathogens, tend to be the major microorganisms that account for port-related infections, and the infections run a benign course, even those developed in septicemia.

Monitoring of creatinine kinase during weaning of intrathecal baclofen and with symptoms of early withdrawal.

Abrupt withdrawal from intrathecal baclofen (ITB) can result in severe rebound spasticity, confusion, and seizures. It has been recently recognized that abrupt withdrawal from ITB may, in rare cases, result in life-threatening rhabdomyolysis, hyperthermia, autonomic disturbances, and sepsis-like presentations. Early recognition of the most severe forms of the withdrawal syndrome is essential for effective intervention. The common and unique features in such individuals seem to be severe increased spasticity and marked elevation in creatinine kinase levels. This case of an individual with T4 paraplegia with recurrent episodes of ITB withdrawal associated with severe spasticity and elevated creatinine kinase levels who required rapid weaning of high-dose ITB to allow removal of an infected pump and catheter illustrates the value of monitoring creatinine kinase levels in evaluation of suspected ITB withdrawal and during rapid weaning of ITB when necessary.

Monitor outcomes for safer infusion therapy, better resource management.

To determine how to properly implement new CDC evidence-based practices, collect, analyze, and apply outcomes data to provided infusion care.