Orthopedic infections due to Trichosporon species: Case series and literature review.

Reports of orthopedic fungal infections caused by Trichosporon species are extremely scarce, thus we aimed to describe a case series and review the cases published in the literature. Patients were retrospectively included if a previous culture of bone, joint, or soft tissues had resulted positive for Trichosporon species along with a clinical diagnosis of an orthopedic infection. Eight patients were included with diverse orthopedic conditions, most of them cases of osteomyelitis. The main isolated species was Trichosporon asahii. All patients were treated with antifungals, mainly voriconazole, and surgical management, resulting in high rates of clinical improvement and low associated mortality.

Reports of orthopedic infections caused by Trichosporon species are scarce. We described a case series of orthopedic infections caused by Trichosporon species and reviewed the previous published cases in the literature. We observed a high rate of clinical improvement and a low associated mortality.

Management of infection by the Zika virus.

A panel of national experts was convened by the Brazilian Infectious Diseases Society in order to organize the national recommendations for the management of zika virus infection. The focus of this document is the diagnosis, both clinical and laboratorial, and appropriate treatment of the diverse manifestations of this infection, ranging from acute mild disease to Guillain-Barré syndrome and also microcephaly and congenital malformations.

Analysis of epidemiological and clinical aspects in cases of fungal osteomyelitis caused by non-Candida species.

Osteomyelitis caused by non-Candida species is rare and often neglected, and current recommendations are based on primarily clinical experience and expert opinion. The objective of this study was to describe a case series of non-Candida fungal osteomyelitis. This retrospective study included 10 patients with non-Candida fungal osteomyelitis. Patients with osteomyelitis and microbiologically confirmed non-Candida species from bone fragment cultures were selected from the institution Infection Control Board database. Fusarium spp. were the most commonly isolated fungus from bone fragment cultures in five patients (50%). The majority did not present immunosuppression. The most common etiology was post-traumatic (n = 7, 70%), particularly open fractures. All patients were treated with antifungals associated with surgery. The antifungals used were itraconazole in five patients (50%), and voriconazole in another five patients (50%), with a median duration of antifungal therapy of four weeks (range: 3-25). There were no observed deaths within 30 days and one year. An antifungal approach combined with surgical treatment demonstrated favorable clinical outcomes, including low mortality rates and effective remission.

Clinical-epidemiological profile of confirmed cases of osteoarticular tuberculosis.

Introduction: tuberculosis (TB) remains a major cause of morbidity and mortality worldwide. The incidence of TB has increased since the 1980s. Given the increasing prevalence of TB worldwide, osteoarticular TB (OATB) is a significant health problem. Methods: retrospective study of a case series of hospitalized patients with confirmed OATB by culture or histopathological examination who were seen at a reference orthopedic hospital in São Paulo, Brazil, from 2014 to 2019. Results: thirty patients with confirmed bone and joint TB were seen from 2014 to 2019. The main sites of OATB were the spine (83.3 %) and the appendicular skeleton (26.7 %). Indication of surgical treatment was significantly related to the need for hospitalization ( p = 0.009 ) and the increased length of hospital stay ( p = 0.005 ). Presence of sequelae at the end of treatment was correlated with the presence of motor deficit at the time of OATB diagnosis ( p = 0.035 ) as well as with initial presence of functional limitation ( p = 0.025 ) and with high value of C-reactive protein at the end of treatment ( p = 0.037 ). Conclusions: the delay in the onset of clinical and laboratory signs of cases of osteoarticular infections hinders the early diagnosis and treatment of the disease, resulting in major complications sometimes requiring surgical treatment and consequently leading to a prolonged hospital stay, evidence of high inflammatory activities, and the presence of neurological deficits.

COVID-19 and isolation: Risks and implications in the scenario of new variants.

With the emergence of new variants of SARS-CoV-2, questions about transmissibility, vaccine efficacy, and impact on mortality are important to support decision-making in public health measures. Modifications related to transmissibility combined with the fact that much of the population has already been partially exposed to infection and/or vaccination, have stimulated recommendations to reduce the isolation period for COVID-19. However, these new guidelines have raised questions about their effectiveness in reducing contamination and minimizing impact in work environments. Therefore, a collaborative task force was developed to review the subject in a non-systematic manner, answering questions about SARS-CoV-2 variants, COVID-19 vaccines, isolation/quarantine periods, testing to end the isolation period, and the use of masks as mitigation procedures. Overall, COVID-19 vaccines are effective in preventing severe illness and death but are less effective in preventing infection in the case of the Omicron variant. Any strategy that is adopted to reduce the isolation period should take into consideration the epidemiological situation of the geographical region, individual clinical characteristics, and mask for source control. The use of tests for isolation withdrawal should be evaluated with caution, due to results depending on various conditions and may not be reliable.

Bioactive glass S53P4 to fill-up large cavitary bone defect after acute and chronic osteomyelitis treated with antibiotic-loaded cement beads: A prospective case series with a minimum 2-year follow-up.

INTRODUCTION: Bioactive glass S53P4 (BAG-S53P4) has been used in the treatment of osteomyelitis with excellent results. The aim of this study was to evaluate the clinical and radiographic results of patients treated with use of antibiotic-loaded cement beads, followed by bone defects filling using bioglass. METHODS: We treated a prospective series of patients presenting with acute or chronic osteomyelitis of a long bone of the upper or lower limb. The first-stage procedure involved debridement and filling of cavitary defects with antibiotic-loaded polymethylmethacrylate (PMMA) beads. When signs of infection subsided, the defects were filled with BAG-S53P4. The main outcomes assessed were the reinfection rate, need for reoperation, radiographic and functional evaluations (DASH and Lysholm scores). RESULTS: Ten patients were included, aged between 4 and 66 years (mean 25.4 years). The source of infection was hematogenic in five cases and post-traumatic in the other five. Hematogenic infections required two debridements before filling with bioglass, whereas post-traumatic cases required only one. The time between the first debridement and the application of bioglass varied from 1 to 63 weeks (average of 17 weeks). All patients showed a favorable evolution after bioglass procedure, with no need for reoperation or relevant wound problems. The radiographic evaluation showed partial incorporation of the material and adequate bone formation, and functional scores were satisfactory in all cases. CONCLUSION: The treatment of osteomyelitis with surgical debridement and PMMA beads, followed by filling of bone defect with BAG-S53P4, was effective in all patients evaluated, with adequate infectious control and bone regeneration. No cases required reoperation after bioglass implantation. Patients with hematogenous osteomyelitis required a greater number of debridements before filling with bioglass.

Prosthetic joint infection due to Candida species: Case series and review of literature.

INTRODUCTION: The increase in the number of patients with prosthetic joints will entail a rise in the absolute number of infections associated with these procedures. Although less frequent, infections by Candida species are also expected to increase, and the clinical and surgical management of these cases is based on case reports and opinion of specialists. The objective of the present study was to review the available literature and describe the cases of prosthetic joint infection caused by Candida species in patients of the Institute of Orthopedics and Trauma of the University of São Paulo Faculty of Medicine Clinics Hospital (IOT-HCFMUSP) between 2007 and 2014. PATIENT CONCERNS: Eleven patients were diagnosed with prosthetic joint infection due to Candida with mean age of 65 years. The most frequent comorbidities were heart disease and diabetes mellitus, and the main personal antecedent was previous bacterial infection in the prosthetic joint. At least one risk factor for fungal infection was present in 73% of the patients. There was no difference between the prevalence of infections caused by Candida albicans and non-albicans Candida species, and there was bacterial co-infection in 55% of the cases. DIAGNOSIS: For building up the case series, patients with cultures of bone and joint specimens that were positive for Candida species and had a clinical diagnosis of prosthetic joint infection were included in the case series. INTERVENTIONS: Surgical debridement with removal of the prosthesis was the most frequently used surgical approach (45%). All patients were treated with monotherapy, and the most frequently used antifungal agent was fluconazole. The total duration of antifungal therapy was 6 months in 73% of the cases. OUTCOMES: After the initial management, 73% of the patients achieved clinical remission. CONCLUSION: The most indicated initial management was debridement with removal of the prosthesis, and the most used treatment regimen was fluconazole monotherapy. The most prevalent treatment duration was 6 months. The initial management led to a favorable outcome in 73% of the cases. DESCRIPTORS: Prosthetic joint infection, Candida, treatment, and diagnosis.

Osteonecrosis of the femoral head in people living with HIV: anatomopathological description and p24 antigen test.

OBJECTIVE: To examine the presence of HIV in bone tissue of people living with HIV (PLWHIV) with osteonecrosis of femoral head and describe clinical and anatomopathological findings. DESIGN: This is a case series which included 44 PLWHIV with osteonecrosis of femoral head who underwent total hip arthroplasty. METHODS: Clinical data were obtained through analysis of the patients' medical records. Bone tissue obtained during total hip arthroplasty was retrieved and sent for conventional and immunohistochemical analysis. Monoclonal antibodies were used to mark the p24 (HIV), CD31 (vascular endothelial cells), CD68 (macrophages), and D240 (cells of the lymphatic endothelium) antigens. RESULTS: Dyslipidemia was found in 48% of the patients and lipodystrophy in 31%. Histological analysis showed similar characteristics for the entire sample. Degeneration of joint cartilage was visualized with the presence of fissures and fibrillations, as well as subchondral sclerosis and necrosis of the subchondral cancellous bone tissue. Lymphoplasmocytic inflammatory reaction was observed, with the presence of macrophages containing a foamy, vacuolated cytoplasm, as well as the presence of ceroid pigment and occasional granulation tissue. The reaction with the monoclonal anti-p24 antibody was negative in the samples from all 44 PLWHIV undergoing hip arthroplasty. Reactions with the anti-CD31 and anti-D240 antibodies were negative. Staining with CD68 antibody confirmed that the cells visualized with foamy, vacuolated cytoplasm were macrophages. CONCLUSION: p24 HIV antigen was not detected in the bone tissue of PLWHIV and osteonecrosis. The most frequent anatomopathological findings were extensive necrosis of bone tissue, large vacuoles filled with fat cells, inflammatory lymphoplasmocytic reaction with macrophages containing vacuolated cytoplasm, and the presence of ceroid pigment.

Osteoarticular complications related to HIV infection and highly active antiretroviral therapy.

With the significant increase in life expectancy for HIV-infected patients in the era of high potency antiretroviral therapy, major metabolic changes have been observed due to the prolonged period of the viral infection and the treatment itself. Osteoarticular changes resulting from these processes are mainly reported in long term HIV-infected patients receiving high potency antiretroviral therapy and include osteopenia/osteoporosis, osteonecrosis, carpal tunnel syndrome and adhesive capsulitis of the shoulder.

COVID-19 and isolation: Risks and implications in the scenario of new variants

Abstract With the emergence of new variants of SARS-CoV-2, questions about transmissibility, vaccine efficacy, and impact on mortality are important to support decision-making in public health measures. Modifications related to transmissibility combined with the fact that much of the population has already been partially exposed to infection and/or vaccination, have stimulated recommendations to reduce the isolation period for COVID-19. However, these new guidelines have raised questions about their effectiveness in reducing contamination and minimizing impact in work environments. Therefore, a collaborative task force was developed to review the subject in a non-systematic manner, answering questions about SARS-CoV-2 variants, COVID-19 vaccines, isolation/quarantine periods, testing to end the isolation period, and the use of masks as mitigation procedures. Overall, COVID-19 vaccines are effective in preventing severe illness and death but are less effective in preventing infection in the case of the Omicron variant. Any strategy that is adopted to reduce the isolation period should take into consideration the epidemiological situation of the geographical region, individual clinical characteristics, and mask for source control. The use of tests for isolation withdrawal should be evaluated with caution, due to results depending on various conditions and may not be reliable.

The incidence and microbiological profile of surgical site infections following internal fixation of closed and open fractures.

OBJECTIVE: To evaluate the incidence and microbiological profile of surgical site infections (SSIs) associated with internal fixation of fractures and to compare differences in the SSIs observed among patients with closed and open fractures. METHODS: Retrospective study. Analyzed data included information from all patients who underwent surgery for fixation of closed or open fractures from January 2005 to December 2012 and remained outpatients for at least one year following surgery. Incidence of surgical site infection (SSI) was compared between patients with closed and open infection, as well as polymicrobial infection and infection related to Gram-negative bacilli (GNB). Cumulative antibiograms were performed to describe microbiological profiles. RESULTS: Overall incidence of SSI was 6%. This incidence was significantly higher among patients with open fractures (14.7%) than among patients with closed fractures (4.2%). The proportions of patients with polymicrobial infections and infections due to GNB were also significantly higher among patients with open fractures. Staphylococcus aureus and coagulase-negative Staphylococcus (CoNS) species were the primary infectious agents isolated from both groups. The overall incidence of MRSA (methicillin-resistant S. aureus) was 72%. A. baumannii was the predominant GNB isolate recovered from patients with open fractures and P. aeruginosa was the most frequent isolate recovered from patients with closed fractures, both exhibited low rates of susceptibility to carbapenems. CONCLUSIONS: Incidence of SSIs related to the internal fixation of fractures was significantly higher among patients with open fractures, indicating that an open fracture can be a risk factor for infection. Among the bacterial isolates, S. aureus (with a high prevalence of MRSA) and CoNS species were most prevalent. A. baumannii and P. aeruginosa isolates underscored the low rate of susceptibility to carbapenems that was observed in the present study.

OBJETIVO: Avaliar a incidência e o perfil microbiológico das ISC relacionadas a procedimentos de fixação de fraturas num hospital acadêmico ortopédico terciário em São Paulo, Brasil, e comparar as diferenças observadas entre os pacientes com fraturas fechadas e expostas. MÉTODOS: Estudo retrospectivo. Foram incluídos na análise os dados relativos a todos os pacientes que passaram por procedimento cirúrgico para fixação de fraturas fechadas ou expostas de janeiro de 2005 a dezembro de 2012 e que mantiveram seguimento por pelo menos um ano. Foi verificada a presença de associação entre o tipo de fratura, a incidência de ISC e as incidências de infecções polimicrobianas e por bacilos Gram-negativos. O perfil microbiológico foi estabelecido por meio da elaboração de antibiogramas cumulativos. RESULTADOS: A incidência geral de infecção de 6%. Essa incidência foi maior no grupo de pacientes com fraturas expostas (14,7%) do que naqueles com fraturas fechadas (4,2%), com diferença estatisticamente significante. O número de pacientes com infecções polimicrobianas e com infecções relacionadas a BGN também foi significativamente maior no grupo de casos relacionados a fraturas expostas. Staphylococcus aureus e espécies de Staphylococcus coagulase-negativo (CoNS) foram os principais agentes isolados nos dois grupos. A incidência de MRSA (S. aureus resistente a meticilina) dentre todos os isolados de S. aureus foi de 72%. A. baumannii foi o principal BGN isolado entre os pacientes com fraturas expostas e P. aeruginosa entre os pacientes com fraturas fechadas. Em ambos os casos, observaram-se baixos índices de sensibilidade a carbapenêmicos. CONCLUSÕES: A incidência de ISC relacionada à fixação interna de fraturas foi significantemente maior nos pacientes com fraturas expostas, o que indica que esse tipo de fratura pode ser um fator de risco para a ocorrência desse tipo de infecção. Dentre os isolados bacterianos, predominaram no geral S. aureus (com elevada prevalência de MRSA) e S. coagulase-negativo. Dentre os BGN, houve predomínio de A. baumanni também entre os isolados de pacientes com fraturas expostas e P. aeruginosa entre os isolados daqueles com fraturas fechadas.

Septic arthritis of the knee: clinical and laboratory comparison of groups with different etiologies.

OBJECTIVES:: To clinically and epidemiologically characterize a population diagnosed with and treated for septic arthritis of the knee, to evaluate the treatment results and to analyze the differences between patients with positive and negative culture results, patients with Gram-positive and Gram-negative bacterial isolates and patients with S. aureus- and non-S. aureus-related infections. METHODS:: One hundred and five patients with septic knee arthritis were included in this study. The clinical and epidemiological data were evaluated. Statistical analysis was performed to compare patients with and without an isolated causative agent, patients with Gram-positive and Gram-negative pathogens and patients with S. aureus-related and non S. aureus-related infections. RESULTS:: Causative agents were isolated in 81 patients. Gram-positive bacteria were isolated in 65 patients and Gram-negative bacteria were isolated in 16 patients. The most commonly isolated bacterium was S. aureus. Comparing cases with an isolated pathogen to cases without an isolated pathogen, no differences between the studied variables were found except for the longer hospital stays of patients in whom an etiological agent was identified. When comparing Gram-positive bacteria with Gram-negative bacteria, patients with Gram-positive-related infections exhibited higher leukocyte counts. Patients with S. aureus-related infections were more frequently associated with healthcare-related environmental encounters. CONCLUSION:: S. aureus is the most common pathogen of septic knee arthritis. Major differences were not observed between infections with isolated and non-isolated pathogens and between infections with Gram-positive and Gram-negative bacteria. S. aureus infections were more likely to be associated with a prior healthcare environment exposure.

Outpatient parenteral antimicrobial therapy for orthopedic infections - a successful public healthcare experience in Brazil.

Treatment of orthopedic infections usually requires prolonged antimicrobial therapy, ranging from 14 days up to 6 months. Nowadays, rising levels of antimicrobial resistance demands parenteral therapy for many patients. Outpatient parenteral antimicrobial therapy (OPAT) is a modality that allows treatment out of hospital in these situations. In Brazil, where a public universal healthcare system allows full coverage for all citizens, implantation and dissemination of OPAT programs would be beneficial for patients and for the system, because it would allow a better allocation of health resources. The Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Faculdade de Medicina da USP (IOT) started, in July 2013, a partnership with municipal health authorities in Sao Paulo, Brazil, in order to initiate an OPAT program in which patients discharged from that hospital would be able to continue antimicrobial therapy at primary care facilities. When necessary, patients could also receive their therapy at the day-hospital located at IOT. Primary care nursing and physician staff were trained about antimicrobial infusion and peripherally inserted central catheter manipulation. An OPAT specific antimicrobial protocol was designed and a special reference and counter-reference organized. As a result, 450 primary healthcare professionals were trained. In the first year of this program, 116 patients were discharged for OPAT. Chronic and acute osteomyelitis were most frequent diagnosis. Teicoplanin, ertapenem and tigecycline were the most used drugs. Duration of treatment varied from 10 to 180 days (average 101, median 42). Total sum of days in OPAT regimen was 11,698. Only 3 patients presented adverse effects. Partnership between services of different levels of complexity allowed implantation of a safe and effective public healthcare OPAT program for treatment of orthopedic infections. This program can serve as a model for developing similar strategies in other regions of Brazil and Latin America.

Clinical and epidemiological differences between septic arthritis of the knee and hip caused by oxacillin-sensitive and -resistant s. aureus.

OBJECTIVE: To establish the risk factors for joint infection by oxacillin-resistant Staphylococcus aureus (MRSA) using clinical and epidemiological data. METHODS: All septic arthritis cases of the knee and hip diagnosed and treated in our institution from 2006 to 2012 were evaluated retrospectively. Only patients with cultures identified as microbial agents were included in the study. The clinical and epidemiological characteristics of the patients were analyzed, seeking the differences between populations affected by MRSA and oxacillin-sensitive Staphylococcus aureus (MSSA). RESULTS: S. aureus was isolated in thirty-five patients (46.0%) in our total sample, 25 in the knee and 10 in the hip. Of these 35 patients, 22 presented with MSSA and 13 presented with MRSA. Provenance from a health service-related environment, as described by the Centers for Disease Control and Prevention, was the only variable associated with oxacillin-resistant strains of this bacterium (p = 0.001). CONCLUSION: Provenance from a health service-related environment was associated with a higher incidence of MRSA-related septic arthritis, suggesting that this agent should be considered in the initial choice of antibiotic treatment. Previous surgeries of the knee or affected limb and the absence of leukocytes might also be related to infection with this agent.

Epidemiology of septic arthritis of the knee at Hospital das Clínicas, Universidade de São Paulo.

BACKGROUND: Septic arthritis is an infrequent disease although very important due to the possibility of disastrous outcomes if treatment is not adequately established. Adequate information concerning the epidemiology of septic arthritis is still lacking due to the uncommon nature of the disease as well as the struggle to establish a correct case-definition. OBJECTIVE: To epidemiologically characterize the population seen at Hospital das Clínicas, University of São Paulo with a diagnosis of septic arthritis between 2006 and 2011. METHODS: Sixty-one patients diagnosed with septic arthritis of the knee between 2006 and 2011 were retrospectively evaluated. The patients' clinical and epidemiological characteristics, the microorganisms that caused the infection and the patients' treatment and evolution were analyzed. RESULTS: Septic arthritis of the knee was more common among men, with distribution across a variety of age ranges. Most diagnoses were made through positive synovial fluid cultures. The most prevalent clinical comorbidities were systemic arterial hypertension and diabetes mellitus, and the most commonly reported joint disease was osteoarthritis. Staphylococcus aureus was the prevailing pathogen. Fever was present in 36% of the cases. All patients presented elevation in inflammatory tests. Gram staining was positive in only 50.8% of the synovial fluid samples analyzed. Six patients presented complications and unfavorable evolution of their condition. CONCLUSION: S. aureus is still the most common pathogen in acute knee infections in our environment. Gram staining, absence of fever and normal leukocyte count cannot be used to rule out septic arthritis.

AVASCULAR NECROSIS OF THE FEMORAL HEAD IN HIV-INFECTED PATIENTS: PRELIMINARY RESULTS FROM SURGICAL TREATMENT FOR CERAMIC-CERAMIC JOINT REPLACEMENT.

OBJECTIVES: To evaluate the initial functional results and early complication rate of ceramic-ceramic total hip replacements among patients living with HIV who presented osteonecrosis of the femoral head. METHOD: Twelve HIV-positive patients with a diagnosis of osteonecrosis of the incongruent femoral head were evaluated using clinical and laboratory criteria and the WOMAC functional scale before and after treatment with joint replacement. RESULTS: We observed that 83.3% of the subjects were taking protease inhibitors, 75% had dyslipidemia and 66.6% had lipodystrophy syndrome. The improvement over the evolution of the WOMAC score was statistically significant at six and twelve months after the operation, in comparison with the preoperative score. We did not observe complications secondary to this procedure. CONCLUSION: Total hip arthroplasty with a ceramic-ceramic implant for treating avascular necrosis of the hip is an appropriate surgical option for this portion of the population. It provides a significant initial functional improvement and a low early complication rate.

Gram-negative osteomyelitis: clinical and microbiological profile.

INTRODUCTION: Despite the growing interest in the study of Gram-negative bacilli (GNB) infections, very little information on osteomyelitis caused by GNB is available in the medical literature. OBJECTIVES AND METHODS: To assess clinical and microbiological features of 101 cases of osteomyelitis caused by GNB alone, between January 2007 and January 2009, in a reference center for the treatment of high complexity traumas in the city of São Paulo. RESULTS: Most patients were men (63%), with median age of 42 years, affected by chronic osteomyelitis (43%) or acute osteomyelitis associated to open fractures (32%), the majority on the lower limbs (71%). The patients were treated with antibiotics as inpatients for 40 days (median) and for 99 days (median) in outpatient settings. After 6 months follow-up, the clinical remission rate was around 60%, relapse 19%, amputation 7%, and death 5%. Nine percent of cases were lost to follow-up. A total of 121 GNB was isolated from 101 clinical samples. The most frequently isolated pathogens were Enterobacter sp. (25%), Acinetobacter baumannii (21%) e Pseudomonas aeruginosa (20%). Susceptibility to carbapenems was about 100% for Enterobacter sp., 75% for Pseudomonas aeruginosa and 60% for Acinetobacter baumannii. CONCLUSION: Osteomyelitis caused by GNB remains a serious therapeutic challenge, especially when associated to nonfermenting bacteria. We emphasize the need to consider these agents in diagnosed cases of osteomyelitis, so that an ideal antimicrobial treatment can be administered since the very beginning of the therapy.

Carbapenem stewardship: positive impact on hospital ecology.

INTRODUCTION: Excessive group 2 carbapenem use may result in decreased bacterial susceptibility. OBJECTIVE: We evaluated the impact of a carbapenem stewardship program, restricting imipenem and meropenem use. METHODS: Ertapenem was mandated for ESBL-producing Enterobacteriaceae infections in the absence of non-fermenting Gram-negative bacilli (GNB) from April 2006 to March 2008. Group 2 carbapenems were restricted for use against GNB infections susceptible only to carbapenems and suspected GNB infections in unstable patients. Cumulative susceptibility tests were done for nosocomial pathogens before and after restriction using Clinical and Laboratory Standards Institute (CLSI) guide-lines.Vitek System or conventional identification methods were performed and susceptibility testing done by disk diffusion according to CLSI.Antibiotic consumption (t-test) and susceptibilities (McNemar's test) were determined. RESULTS: The defined daily doses (DDD) of group 2 carbapenems declined from 61.1 to 48.7 DDD/1,000 patient-days two years after ertapenem introduction (p = 0.027). Mean ertapenem consumption after restriction was 31.5 DDD/1,000 patient-days. Following ertapenem introduction no significant susceptibility changes were noticed among Gram-positive cocci. The most prevalent GNB were P. aeruginosa, Klebsiella pneumoniae, and Acinetobacter spp. There was no change in P. aeruginosa susceptibility to carbapenems. Significantly improved P. aeruginosa and K. pneumoniae ciprofloxacin susceptibilities were observed, perhaps due to decreased group 2 carbapenem use. K. pneumoniae susceptibility to trimethoprim-sulfamethoxazole improved. CONCLUSION: Preferential use of ertapenem resulted in reduced group 2 carbapenem use, with a positive impact on P. aeruginosa and K. pneumoniae susceptibility.

The incidence and microbiological profile of surgical site infections following internal fixation of closed and open fractures / Infecção de sítio cirúrgico após fixação de fraturas fechadas e expostas - Incidência e perfil microbiológico

ABSTRACT OBJECTIVE: To evaluate the incidence and microbiological profile of surgical site infections (SSIs) associated with internal fixation of fractures and to compare differences in the SSIs observed among patients with closed and open fractures. METHODS: Retrospective study. Analyzed data included information from all patients who underwent surgery for fixation of closed or open fractures from January 2005 to December 2012 and remained outpatients for at least one year following surgery. Incidence of surgical site infection (SSI) was compared between patients with closed and open infection, as well as polymicrobial infection and infection related to Gram-negative bacilli (GNB). Cumulative antibiograms were performed to describe microbiological profiles. RESULTS: Overall incidence of SSI was 6%. This incidence was significantly higher among patients with open fractures (14.7%) than among patients with closed fractures (4.2%). The proportions of patients with polymicrobial infections and infections due to GNB were also significantly higher among patients with open fractures. Staphylococcus aureus and coagulase-negative Staphylococcus (CoNS) species were the primary infectious agents isolated from both groups. The overall incidence of MRSA (methicillin-resistant S. aureus) was 72%. A. baumannii was the predominant GNB isolate recovered from patients with open fractures and P. aeruginosa was the most frequent isolate recovered from patients with closed fractures, both exhibited low rates of susceptibility to carbapenems. CONCLUSIONS: Incidence of SSIs related to the internal fixation of fractures was significantly higher among patients with open fractures, indicating that an open fracture can be a risk factor for infection. Among the bacterial isolates, S. aureus (with a high prevalence of MRSA) and CoNS species were most prevalent. A. baumannii and P. aeruginosa isolates underscored the low rate of susceptibility to carbapenems that was observed in the present study.

RESUMO OBJETIVO: Avaliar a incidência e o perfil microbiológico das ISC relacionadas a procedimentos de fixação de fraturas num hospital acadêmico ortopédico terciário em São Paulo, Brasil, e comparar as diferenças observadas entre os pacientes com fraturas fechadas e expostas. MÉTODOS: Estudo retrospectivo. Foram incluídos na análise os dados relativos a todos os pacientes que passaram por procedimento cirúrgico para fixação de fraturas fechadas ou expostas de janeiro de 2005 a dezembro de 2012 e que mantiveram seguimento por pelo menos um ano. Foi verificada a presença de associação entre o tipo de fratura, a incidência de ISC e as incidências de infecções polimicrobianas e por bacilos Gram-negativos. O perfil microbiológico foi estabelecido por meio da elaboração de antibiogramas cumulativos. RESULTADOS: A incidência geral de infecção de 6%. Essa incidência foi maior no grupo de pacientes com fraturas expostas (14,7%) do que naqueles com fraturas fechadas (4,2%), com diferença estatisticamente significante. O número de pacientes com infecções polimicrobianas e com infecções relacionadas a BGN também foi significativamente maior no grupo de casos relacionados a fraturas expostas. Staphylococcus aureus e espécies de Staphylococcus coagulase-negativo (CoNS) foram os principais agentes isolados nos dois grupos. A incidência de MRSA (S. aureus resistente a meticilina) dentre todos os isolados de S. aureus foi de 72%. A. baumannii foi o principal BGN isolado entre os pacientes com fraturas expostas e P. aeruginosa entre os pacientes com fraturas fechadas. Em ambos os casos, observaram-se baixos índices de sensibilidade a carbapenêmicos. CONCLUSÕES: A incidência de ISC relacionada à fixação interna de fraturas foi significantemente maior nos pacientes com fraturas expostas, o que indica que esse tipo de fratura pode ser um fator de risco para a ocorrência desse tipo de infecção. Dentre os isolados bacterianos, predominaram no geral S. aureus (com elevada prevalência de MRSA) e S. coagulase-negativo. Dentre os BGN, houve predomínio de A. baumanni também entre os isolados de pacientes com fraturas expostas e P. aeruginosa entre os isolados daqueles com fraturas fechadas.