Clinical Effectiveness of Continuous Infusion Flucloxacillin in the Outpatient Parenteral Antimicrobial Therapy (OPAT) Setting in a UK Hospital: A Service Evaluation.

The availability of stability data for the use of continuous intravenous flucloxacillin in an elastomeric device has enabled the treatment of serious Methicillin Sensitive Staphylococcus aureus (MSSA) in the outpatient parenteral antimicrobial therapy (OPAT) setting. This service review aimed to evaluate current standard of care to establish the clinical effectiveness and complication rates associated with its use since its introduction at our institution. A retrospective review of clinical outcomes and adverse events/complications, was undertaken for all patients who received continuous infusion flucloxacillin for complicated MSSA infection between January 2019 and July 2022 via our OPAT service. Thirty-nine patients were included. An OPAT treatment outcome of 'Treatment aim attained uncomplicated' was achieved in 29/39 (74%) patients. Two patients had an OPAT treatment outcome of treatment aim not attained, both of which required unexpected hospital re-admission. An adverse event/complication occurred in 8 patients. There were two relapses in the 12-month follow-up period. Our review supports the assertion that continuous infusion flucloxacillin is clinically effective and well tolerated for the treatment of complicated MSSA infection in the OPAT setting.

Outpatient parenteral antimicrobial therapy (OPAT) in the UK: findings from the BSAC National Outcomes Registry (2015-19).

BACKGROUND: Reporting of outpatient parenteral antimicrobial therapy (OPAT) outcomes with national benchmarking is key to informing service development and supporting quality improvement. OBJECTIVES: To analyse and report on data collected by the BSAC OPAT National Outcomes Registry from 2015 to 2019. METHODS: Quarterly data to 2020 was extracted from the BSAC National Outcomes Registry and analysed. RESULTS: 57 organizations submitted data on 27 841 patient episodes and 442 280 OPAT treatment days. A diverse range of infections and antimicrobials were reported with a mean OPAT treatment duration of 16.7 days (adults) and 7.7 days (paediatrics). In adults, the top five conditions treated were skin and soft tissue (27.6%), bronchiectasis (11.4%), urinary tract infections (7.6%), and diabetic foot infections (5.5%). Ceftriaxone followed by teicoplanin, ertapenem and piperacillin/tazobactam were the most-used antimicrobials. A median of 1.4 vascular-device-related complications were observed per 1000 OPAT treatment days (range 0.11 to 10.4) with device infections in 0.3 per 1000 OPAT days (range 0.1 to 1.7). Other adverse events (rash, blood dyscrasias, antibiotic-associated diarrhoea) were observed in a median of 1.9 per 1000 OPAT days. OPAT infection outcome (cured/improved) was 92.4% and OPAT outcome (success/partial success) was 90.7%. CONCLUSIONS: This report demonstrates the safety, breadth, and complexity of modern UK OPAT practice. Future analyses of OPAT data should focus on infection- and service-specific quality indicators. OPAT registries remain central to planning and assessing safe, effective, and efficient delivery of patient-centred care and should be an important focus for UK and global OPAT practice.

Outcomes of single- and two-stage revision total knee arthroplasty for chronic periprosthetic joint infection : long-term outcomes of changing clinical practice in a specialist centre.

AIMS: Single-stage revision total knee arthroplasty (rTKA) is gaining popularity in treating chronic periprosthetic joint infections (PJIs). We have introduced this approach to our clinical practice and sought to evaluate rates of reinfection and re-revision, along with predictors of failure of both single- and two-stage rTKA for chronic PJI. METHODS: A retrospective comparative cohort study of all rTKAs for chronic PJI between 1 April 2003 and 31 December 2018 was undertaken using prospective databases. Patients with acute infections were excluded; rTKAs were classified as single-stage, stage 1, or stage 2 of two-stage revision. The primary outcome measure was failure to eradicate or recurrent infection. Variables evaluated for failure by regression analysis included age, BMI, American Society of Anesthesiologists grade, infecting organisms, and the presence of a sinus. Patient survivorship was also compared between the groups. RESULTS: A total of 292 consecutive first-time rTKAs for chronic PJI were included: 82 single-stage (28.1%); and 210 two-stage (71.9%) revisions. The mean age was 71 years (27 to 90), with 165 females (57.4%), and a mean BMI of 30.9 kg/m2 (20 to 53). Significantly more patients with a known infecting organism were in the single-stage group (93.9% vs 80.47%; p = 0.004). The infecting organism was identified preoperatively in 246 cases (84.2%). At a mean follow-up of 6.3 years (2.0 to 17.6), the failure rate was 6.1% in the single-stage, and 12% in the two-stage groups. All failures occurred within four years of treatment. The presence of a sinus was an independent risk factor for failure (odds ratio (OR) 4.97; 95% confidence interval (CI) 1.593 to 15.505; p = 0.006), as well as age > 80 years (OR 5.962; 95% CI 1.156 to 30.73; p = 0.033). The ten-year patient survivorship rate was 72% in the single-stage group compared with 70.5% in the two-stage group. This difference was not significant (p = 0.517). CONCLUSION: Single-stage rTKA is an effective strategy with a high success rate comparable to two-stage approach in appropriately selected patients. Cite this article: Bone Joint J 2021;103-B(8):1373-1379.

Periprosthetic joint infection with Ureaplasma parvum detected by 16S rRNA PCR.

Usual culture methods to identify pathogenic bacteria can be unsuccessful, particularly when working with fastidious organisms. We present a case of early periprosthetic knee joint infection with Ureaplasma parvum only identified using 16S ribosomal RNA PCR. This case represents the impact molecular methods of bacterial identification can have on clinical care allowing for more targeted antimicrobial therapy; something which is imperative in an era of increasing antimicrobial resistance.

Septic Revision Total Knee Arthroplasty Is Associated With Significantly Higher Mortality Than Aseptic Revisions: Long-Term Single-Center Study (1254 Patients).

BACKGROUND: The aim of this study is to examine the differences in long-term mortality rates between septic and aseptic revision total knee arthroplasty (rTKA) in a single specialist center over 17-year period. METHODS: Retrospective consecutive study of all patients who underwent rTKA at our tertiary center between 2003 and 2019 was carried out. Revisions were classified as septic or aseptic. We identified patients' age, gender, American Society of Anesthesiologists grade, and body mass index. The primary outcome measure was all-cause mortality at 5 years, 10 years, and over the whole study period of 17 years. Death was identified through both local hospital electronic databases and linked data from the National Joint Registry/NHS Personal Demographic Service. Kaplan-Meier survival curves were used to estimate time to death. RESULTS: In total, 1298 consecutive knee revisions were performed on 1254 patients (44 bilateral revisions) with 985 aseptic revisions in 945 patients (75.4%) and 313 septic revisions in 309 patients (24.6%). Average age was 70.6 years (range 27-95) with 720 females (57.4%). Septic revisions had higher mortality rates; patients' survivorship for septic vs aseptic revisions was 77.6% vs 89.5% at 5 years, 68.7% vs 80.2% at 10 years, and 66.1% vs 75.0% at 17 years; these differences were all statistically significant (P < .0001). The unadjusted 10-year risk ratio of death after septic revision was 1.59 (95% confidence interval 1.29-1.96) compared to aseptic revisions. CONCLUSION: rTKA performed for infection is associated with significantly higher long-term mortality at all time points compared with aseptic revision surgery. LEVEL OF EVIDENCE: Level IV.

Updated good practice recommendations for outpatient parenteral antimicrobial therapy (OPAT) in adults and children in the UK.

UK good practice recommendations for outpatient parenteral antimicrobial therapy (OPAT) were published in 2012 and 2015 for adult and paediatric patients, respectively. Here we update the initial good practice recommendations in a combined document based on a further review of the OPAT literature and an extensive consultation process. As with the previous good practice recommendations, these updated recommendations are intended to provide pragmatic guidance for new and established OPAT services across a range of settings and to act as a set of quality indicators for service evaluation and quality improvement.

Interface Scopulariopsis gracilis fungal keratitis following Descemet's stripping automated endothelial keratoplasty (DSAEK) with a contaminated graft.

PURPOSE: To report for the first time a case of interface Scopulariopsis gracilis fungal keratitis following Descemet's stripping automated endothelial keratoplasty (DSAEK) with a contaminated graft. METHODS: A 57-year-old man with bilateral keratoconus and previous bilateral penetrating keratoplasties (PK) developed graft failure in association with marked corneal ectasia. He underwent a successful DSAEK. Unfortunately, a contaminated graft was transplanted and the following morning we were contacted by the eye bank to inform us a slow-growing fungus had been detected in the culture plates inoculated with dextran solution used to store the issued corneoscleral button. Immediate patient review revealed four infiltrates in the interface between the donor and the recipient tissue. The patient returned to theatre for the removal of the infected graft and was successfully treated with topical amphotericin 0.15%, voriconazole 1% and oral voriconazole and later oral itraconazole. Two intracameral injections of 5 µg in 0.1 ml of amphotericin B were also performed. RESULTS: A reference laboratory cultured and identified the fungus as Scopulariopsis gracilis species. The patient responded to treatment and eventually achieved a spectacle-corrected logMAR visual acuity of 0.3 following a delayed PK. CONCLUSION: Scopulariopsis gracilis fungal keratitis is a rare infection, and the species can be difficult to eradicate. This is the first case report of an infection secondary to a contaminated graft with the species, and we report its successful treatment with an excellent visual outcome.

Aciclovir desensitisation and rechallenge.

A 29-year-old patient with HIV developed a facial angioedema hypersensitivity reaction to aciclovir when treated for acute retinal necrosis secondary to a herpes virus infection. She developed a similar reaction to famciclovir. Successful rapid desensitisation with oral aciclovir was performed and she became tolerant to aciclovir. She successfully completed 28 months of continuous treatment with no further reactions. However, 28 months later she experienced blurred vision and resumed taking oral aciclovir without a preceding desensitisation regimen. No allergic reaction occurred.

Valganciclovir treatment of primary cytomegalovirus pneumonitis in an immunocompetent adult.

Interstitial pneumonitis is a rare complication of cytomegalovirus (CMV) infection in the immunocompetent. There is a paucity of literature regarding treatment in these patients. A previously healthy, immunocompetent female patient presented with fever, shortness of breath, a dry non-productive cough and myalgia and was subsequently diagnosed with CMV interstitial pneumonitis. She was treated with valganciclovir and swiftly improved but experienced neutropenia, which resolved on treatment cessation.

Effect of synbiotic therapy on the incidence of ventilator associated pneumonia in critically ill patients: a randomised, double-blind, placebo-controlled trial.

OBJECTIVE: To investigate the effect of enteral Synbiotic 2000 FORTE (a mixture of lactic acid bacteria and fibre) on the incidence of ventilator associated pneumonia (VAP) in critically ill patients. DESIGN: Prospective, randomised, double blind, placebo controlled trial. SETTING: Tertiary referral centre, general Adult Intensive Care Unit (ICU). PATIENTS AND PARTICIPANTS: 259 enterally fed patients requiring mechanical ventilation for 48 h or more were enrolled. INTERVENTION: All patients were enterally fed as per a standard protocol and randomly assigned to receive either synbiotic 2000 FORTE (twice a day) or a cellulose-based placebo for a maximum of 28 days. MEASUREMENTS AND RESULTS: Treatment group (n = 130) was well matched with placebo group (n = 129) for age (mean 49.5 and 50 years, respectively) and APACHE II score (median 17 for both). Oropharyngeal microbial flora and colonisation rates were unaffected by synbiotics. The overall incidence of VAP was lower than anticipated (11.2%) and no statistical difference was demonstrated between groups receiving synbiotic and placebo in the incidence of VAP (9 and 13%, P = 0.42), VAP rate per 1,000 ventilator days (13 and 14.6, P = 0.91) or hospital mortality (27 and 33%, P = 0.39), respectively. CONCLUSIONS: Enteral administration of Synbiotic 2000 FORTE has no statistically significant impact on the incidence of VAP in critically ill patients.