Local antibiotic delivery via intra-articular catheter infusion for the treatment of periprosthetic joint infection: a systematic review.

INTRODUCTION: There is an increasing interest in the use of intra-articular (IA) antibiotic infusion as a stand-alone or adjuvant therapy to standard revision surgery for periprosthetic joint infection (PJI). The objective of this systematic review is to evaluate the evidence with respect to this up-and-coming treatment modality. METHODS: A systematic review of studies published until April 2023 was conducted using PubMed, Embase, MEDLINE and Cochrane databases. Quality assessment was performed with the National Institute of Health quality assessment tool. Inclusion criteria were adult patients (≥ 18 years) with a mean follow-up of ≥ 11 months and a score ≥ 6 on the National Institute of Health quality assessment tool. Primary outcome was eradication of infection. RESULTS: 15 articles, encompassing 631 PJIs in 626 patients, were included in the final analysis, all level IV case series. The majority was treated with single-stage revision with adjuvant IA antibiotic infusion (79.1%). The remaining PJIs were treated with stand-alone IA antibiotic infusion (12.2%), DAIR (debridement, antibiotics and implant retention) with adjuvant IA antibiotic infusion (5.7%) or two-stage revision with adjuvant IA antibiotic infusion (3.0%). Mean duration of IA antibiotic infusion was 19 days (range 3-50). An overall failure rate of approximately 11% was found. In total 117 complications occurred, 71 were non-catheter-related and 46 were catheter-related. The most common catheter-related complications were premature loss of the catheter (18/46) and elevated blood urea nitrogen (BUN) and creatinine levels (12/46). CONCLUSIONS: Due to the lack of comparative studies the (added) benefit of IA antibiotic infusion in the treatment of PJI remains uncertain. Based on the current evidence, we would advise against using it as a stand-alone treatment. A prospective randomized controlled trial using a well-described infusion protocol is needed to see if the potential benefits justify the increased costs and potential complications of this treatment modality.

Bacteriophage therapy as a treatment strategy for orthopaedic-device-related infections: where do we stand?

Antibiotic resistance represents a key challenge of the 21st century. Since the pipeline of new antibiotics in development is limited, the introduction of alternative antimicrobial strategies is urgently required. Bacteriophage therapy, the use of bacterial viruses to selectively kill bacterial pathogens, is re-emerging as a potential strategy to tackle difficult-to-treat and multidrug-resistant pathogens. The last decade has seen a surge in scientific investigation into bacteriophage therapy, including targeting orthopaedic-device-related infections (ODRIs) in several successful case studies. However, pharmacological data, knowledge on the interplay with the immune system and, especially in ODRIs, the optimal local application strategy and treatment outcomes remain scarce. The present review reports the state-of-the-art in bacteriophage therapy in ODRIs and addresses the hurdles in establishing bacteriophage therapy under good clinical practice guidelines. These hurdles include a lack of data concerning bacteriophage production, processing, administration and dosing, as well as follow-up clinical monitoring reports. To overcome these challenges, an integrated clinical approach is required, supported by comprehensive legislature to enable expansive and correctly implemented clinical trials.

Gallbladder cancer as unexpected finding at cholecystectomy for benign disease.

In 1,000 cholecystectomies for symptomatic presumed benign disease, 23 gallbladder cancers were unexpectedly found. Only six of these 23 patients seemed to benefit from the surgical intervention. In view of the mortality of 0.8% of all cholecystectomies performed, it can be concluded that cholecystectomy for symptomatic gallstones is inadequate to prevent mortality from unexpected gallbladder cancer. To improve the overall prognosis of gallbladder cancer, it is therefore suggested to perform prophylactic cholecystectomy for silent gallstones.

Small bowel diverticulosis. A forgotten diagnosis.

Small bowel diverticulosis (SBD) have the lowest incidence of diverticulosis of the alimentary tract. The incidence differs from 0.09% to 2.3% depending on the reporting physician. SBD are pseudodiverticula, consisting of mucosa only. The causes of SBD are not clear, but the "locus minoris resistentiae" theory is most widely accepted. Overactive or irregular peristalsis bulges the mucosa out through vascular defects in the bowel wall. Only meticulous radiographic techniques can lead to a diagnosis. Preoperative diagnosis is exceptional. SBD can produce chronic abdominal discomfort. Acute complications are also numerously described, giving rise to a surgical emergency. Resection of the involved segment is then the only good procedure. Two cases presenting major complications are discussed, followed by a review of the literature.