Impact of antibiotic prophylaxis in second-stage surgery in joint prosthesis infection treated with two-stage exchange. A multicenter case-control study.

INTRODUCTION: After two-stage exchange due to prosthetic joint infection (PJI), the new prosthesis carries a high risk of reinfection (RePJI). There isn`t solid evidence regarding the antibiotic prophylaxis in 2nd-stage surgery. The objective of this study is to describe what antibiotic prophylaxis is used in this surgery and evaluate its impact on the risk of developing RePJI. METHODS: Retrospective multicenter case-control study in Spanish hospitals. The study included cases of PJI treated with two-stage exchange and subsequently developed a new infection. For each case, two controls were included, matched by prosthesis location, center, and year of surgery. The prophylaxis regimens were grouped based on their antibacterial spectrum, and we calculated the association between the type of regimen and the development of RePJI using conditional logistic regression, adjusted for possible confounding factors. RESULTS: We included 90 cases from 12 centers, which were compared with 172 controls. The most frequent causative microorganism was Staphylococcus epidermidis with 34 cases (37.8%). Staphylococci were responsible for 50 cases (55.6%), 32 of them (64%) methicillin-resistant. Gram-negative bacilli were involved in 30 cases (33.3%), the most common Pseudomonas aeruginosa. In total, 83 different antibiotic prophylaxis regimens were used in 2nd-stage surgery, the most frequent a single preoperative dose of cefazolin (48 occasions; 18.3%); however, it was most common a combination of a glycopeptide and a beta-lactam with activity against Pseudomonas spp (99 cases, 25.2%). In the adjusted analysis, regimens that included antibiotics with activity against methicillin-resistant staphylococci AND Pseudomonas spp were associated with a significantly lower risk of RePJI (adjusted OR = 0.24; 95% IC: 0.09-0.65). CONCLUSIONS: The lack of standardization in 2nd-satge surgery prophylaxis explains the wide diversity of regimens used in this procedure. The results suggest that antibiotic prophylaxis in this surgery should include an antibiotic with activity against methicillin-resistant staphylococci and Pseudomonas.

Etiology and antimicrobial resistance patterns in chronic osteomyelitis of the tibia: an 11-year clinical experience.

PURPOSE: To analyze changes in tendency of etiology and of antimicrobial resistance patterns to most common local and systemic antibiotics in chronic osteomyelitis of the tibia (COM-T) in a Level I trauma center over an 11-year period. METHODS: A retrospective review including all patients with COM-T who were surgically treated from January 2009 to December 2019. Patients were divided into two period groups: 2009-2014 and 2015-2019. Microbiologic etiology was analyzed. Bacterial resistance patterns evaluation was based on the Magiorakos et al. classification, including proportions of multidrug-resistant organisms (MDROs, acquired non-susceptibility to at least one agent in three or more antimicrobial categories), extensively drug-resistant (XDR) and pan drug-resistant (PDR) organisms encountered. RESULTS: A total of 173 episodes of COM-T were identified. Monomicrobial infections represented 47.4% of all cases, while 28.3% had polymicrobial infections. Negative deep-bone cultures were identified in 24.3% of the patients. The most commonly isolated microorganisms were coagulase-negative Staphylococci (24.5%) and S. aureus (20.5%). No differences were found when comparing Gram-positive infections between periods (58.3% for 2009-2014 vs. 46.7% for 2015-2019; p = 0.10). Findings were similar for Gram-negative infections (37% vs. 33.7%; p = 0.62), although more polymicrobial infections were detected (24.7% vs. 33.3%, respectively; p = 0.359). MDROs were involved in 15% of the cases, with an upward trend when comparing both periods (12.8% vs. 23.6%; p = 0.07). The most-used combination of local antibiotics-glycopeptide (vancomycin) plus aminoglycoside (gentamicin or tobramycin)-was met with low rates of resistance in the most frequently isolated microorganisms. CONCLUSION: According to the results of the present study, rates of Gram-positive and Gram-negative infections remained consistent during the two study periods, but with an upward trend in MDRO and polymicrobial infections detected. The local combination of a glycopeptide plus an aminoglycoside was effective in treating the most frequently isolated microorganisms.

Prosthetic joint infection caused by an atypical gram-negative bacilli: Odoribactersplanchnicus.

Prosthetic joint infection (PJI) is a devastating complication after total hip arthroplasty. Its management consists of both: a radical debridement and implant retention or exchange (depending on the timing of symptoms) and directed antibiotic therapy. Thus, the isolation of atypical microorganisms implies a challenge, where anaerobes are responsible for only 4% of cases. However, Odoribacter splanchnicus has not been reported as a cause of PJI yet. We present an 82 year-old woman who was diagnosed with hip PJI. A radical debridement, prosthetic withdrawal, and spacer introduction was performed. Despite the directed antibiotic therapy against E. coli which was first isolated, the patient persisted clinically febrile. An anaerobic Gram-negative rod was isolated and finally, Odoribacter splanchnicus was identified and confirmed by 16S rRNA gene sequencing. Then, antibiotic bitherapy with ciprofloxacin and metronidazole was started until 6 weeks after surgery. The patient had no signs of infection recurrence after then. This case report also shows the importance of genomic identification of rare microorganisms causing PJI, and also allows setting a directed antibiotic therapy which is crucial for infection eradication.

Ceftazidime-Avibactam plus Aztreonam for the Treatment of Infections by VIM-Type-Producing Gram-Negative Bacteria.

This is a retrospective single-center study of 24 patients who received ceftazidime-avibactam plus aztreonam (CZA/ATM) for the treatment of VIM-type-producing Gram-negative bacillus (GNB) infections. The bacteria isolated were Enterobacterales in 22 patients and Pseudomonas aeruginosa in 2. Sixteen out of 19 isolates showed synergistic activity. Two patients presented clinical failure at day 14, and the 30-day mortality was 17% (4/24). CZA/ATM could be considered an alternative therapy for VIM-type-producing GNB infections.

Empirical use of ß-lactam/ß-lactamase inhibitor combinations does not increase mortality compared with cloxacillin and cefazolin in methicillin-susceptible Staphylococcus aureus bacteraemia: a propensity-weighted cohort study.

OBJECTIVES: To evaluate the effectiveness of empirical therapy with ß-lactam/ß-lactamase inhibitor combinations (BL/BLICs) for MSSA bacteraemia. METHODS: We conducted a post hoc analysis of all adult patients with MSSA bacteraemia who were hospitalized at a Spanish university hospital between 2013 and 2018. We compared 30 day mortality among patients receiving initial therapy with BL/BLICs (de-escalated to cloxacillin or cefazolin within 96 h) versus cloxacillin or cefazolin, using propensity score analysis with the inverse probability of treatment weighting (IPTW) method. RESULTS: We evaluated 373 patients with MSSA bacteraemia. Among them, 198 patients met the eligibility criteria, including 127 patients in the BL/BLICs group and 71 patients in the cloxacillin/cefazolin group. Patients in the BL/BLICs group had a higher Charlson comorbidity index (median, 2 [IQR, 1-4.5] versus 2 [IQR, 0-4]); an increased proportion of high-risk sources (i.e. endocarditis, respiratory sources and bacteraemia of unknown origin [34.6% versus 18.3%]); and an earlier start of antibiotic treatment (median, 0 days [IQR, 0-0] versus 1 day [IQR, 1-2]). Thirty day mortality did not significantly differ between the BL/BLICs and the cloxacillin/cefazolin groups (27 patients [21.3%] versus 13 patients [18.3%]; IPTW-adjusted OR = 0.53 [95% CI, 0.18-1.51]). For secondary outcomes, 7 day mortality and 90 day relapse were not statistically different between study groups (8.7% versus 5.6% [P = 0.62] and 6.2% versus 3.8% [P = 0.81], respectively). CONCLUSIONS: BL/BLICs might be an effective empirical treatment for MSSA bacteraemia when de-escalated to cloxacillin or cefazolin within 96 h from the index blood culture.

Fidaxomicin monotherapy versus standard therapy combined with bezlotoxumab for treating patients with Clostridioides difficile infection at high risk of recurrence: a matched cohort study.

BACKGROUND: Both fidaxomicin and bezlotoxumab (used in combination with an antibiotic against Clostridioides difficile) achieve reductions in recurrence rates of C. difficile infection (CDI). However, the two strategies have never been compared. METHODS: Data from two retrospective cohorts of 'real-life' use of fidaxomicin and bezlotoxumab in combination with a standard anti-C. difficile antibiotic were used to compare the rates of recurrence of both strategies. Since the two cohorts were not identical, we used a propensity score analysis. RESULTS: Three hundred and two patients were included: 244 in the fidaxomicin cohort and 78 in the bezlotoxumab cohort. A history of renal failure or immunosuppression was more frequent in patients receiving bezlotoxumab (39.7% and 66.7% versus 26.6% and 38.9%; P = 0.03 and P < 0.001, respectively), but the severity and number of previous CDI episodes were similar in both cohorts. We observed that 19.3% of the patients in the fidaxomicin cohort experienced recurrence, compared with 14.1% in the bezlotoxumab cohort (OR 1.45; 95% CI 0.71-2.96; P = 0.29) but the difference remained non-significant after propensity score matching using previously defined variables (OR 1.24; 95% CI 0.50-3.07; P = 0.64). Moreover, the multivariate analysis did not show differences depending on the drug used. CONCLUSIONS: We observed that fidaxomicin and bezlotoxumab are prescribed in similar clinical scenarios, although those treated with bezlotoxumab have greater comorbidity. The proportion of recurrences was numerically lower in those treated with bezlotoxumab, although the propensity analysis did not find significant differences between the two drugs.

Infections after spine instrumentation: effectiveness of short antibiotic treatment in a large multicentre cohort.

BACKGROUND AND OBJECTIVES: Available information about infection after spine instrumentation (IASI) and its management are scarce. We aimed to analyse DAIR (debridement, antibiotics and implant retention) prognosis and evaluate effectiveness of short antibiotic courses on early forms. METHODS: Multicentre retrospective study of patients with IASI managed surgically (January 2010-December 2016). Risk factors for failure were analysed by multivariate Cox regression and differences between short and long antibiotic treatment were evaluated with a propensity score-matched analysis. RESULTS: Of the 411 IASI cases, 300 (73%) presented in the first month after surgery, 48 in the second month, 22 in the third and 41 thereafter. Infections within the first 2 months (early cases) occurred mainly to older patients, with local inflammatory signs and predominance of Enterobacteriaceae, unlike those in the later periods. When managed with DAIR, prognosis of early cases was better than later ones (failure rate 10.4% versus 26.1%, respectively; P = 0.02). Risk factors for DAIR failure in early cases were female sex, Charlson Score, large fusions (>6 levels) and polymicrobial infections (adjusted HRs of 2.4, 1.3, 2.6 and 2.26, respectively). Propensity score matching proved shorter courses of antibiotics (4-6 weeks) as effective as longer courses (failure rates 11.4% and 10.5%, respectively; P = 0.870). CONCLUSIONS: IASIs within the first 2 months could be managed effectively with DAIR and shorter antibiotic courses. Clinicians should be cautious when faced with patients with comorbidities, large fusions and/or polymicrobial infections.

Role of asymptomatic bacteriuria on early periprosthetic joint infection after hip hemiarthroplasty. BARIFER randomized clinical trial.

PURPOSE: To evaluate preoperative asymptomatic bacteriuria (ASB) treatment to reduce early-periprosthetic joint infections (early-PJIs) after hip hemiarthroplasty (HHA) for fracture. METHODS: Open-label, multicenter RCT comparing fosfomycin-trometamol versus no intervention with a parallel follow-up cohort without ASB. PRIMARY OUTCOME: early-PJI after HHA. RESULTS: Five hundred ninety-four patients enrolled (mean age 84.3); 152(25%) with ASB (77 treated with fosfomycin-trometamol/75 controls) and 442(75%) without. Despite the study closed without the intended sample size, ASB was not predictive of early-PJI (OR: 1.06 [95%CI: 0.33-3.38]), and its treatment did not modify early-PJI incidence (OR: 1.03 [95%CI: 0.15-7.10]). CONCLUSIONS: Neither preoperative ASB nor its treatment appears to be risk factors of early-PJI after HHA. ClinicalTrials.gov Identifier: Eudra CT 2016-001108-47.

Vancomycin-Gentamicin Prefabricated Spacers in 2-Stage Revision Arthroplasty for Chronic Hip and Knee Periprosthetic Joint Infection: Insights Into Reimplantation Microbiology and Outcomes.

BACKGROUND: Second-stage positive cultures in 2-stage revision arthroplasty are a matter of concern, as their influence in outcomes is not clearly defined. We sought to study reimplantation microbiology when using vancomycin-gentamicin prefabricated cement spacers in hip and knee periprosthetic joint infection. The associations of second-stage positive cultures with treatment failures and patient-associated factors were analyzed. METHODS: We conducted a retrospective cohort study, examining patients managed with 2-stage revision arthroplasty due to knee or hip chronic periprosthetic joint infection between 2010 and 2017. Prefabricated vancomycin-gentamicin cement spacers were used during the spacer stage. Intraoperative microbiological culture results after the first and second stages were evaluated. The primary end point was infection eradication or relapse. RESULTS: A total of 108 cases were included (61 hips and 47 knees). And 22.2% of patients had ≥1 second-stage positive culture, while 9.3% had ≥2 positive samples. Overall success, at an average follow-up of 46.4 months, was 77.8%. Treatment failure was higher among cases with positive cultures (15.5% vs 45.8%, P < .01) regardless of the number of positive samples. Diabetes was identified as a risk factor for second-stage positive cultures (P = .03); use of cement loaded with extra antibiotics for spacer fixation showed a protective effect (P < .01). CONCLUSION: Second-stage positive cultures were related to a higher failure rate when using vancomycin-gentamicin cement spacers. Diabetes increased the likelihood of second-stage positive cultures. The use of extra-antibiotic-loaded cement for spacer fixation during the first stage showed a protective effect.

Early Oral Switch to Linezolid for Low-risk Patients With Staphylococcus aureus Bloodstream Infections: A Propensity-matched Cohort Study.

BACKGROUND: Oral switch to linezolid is a promising alternative to standard parenteral therapy (SPT) in Staphylococcus aureus bacteremia (SAB). METHODS: We conducted a prospective cohort study of all adult cases of SAB between 2013 and 2017 in a Spanish university hospital. We compared the efficacy, safety, and length of hospital stay of patients receiving SPT and those where SPT was switched to oral linezolid between days 3 and 9 of treatment until completion. We excluded complicated SAB and osteoarticular infections. A k-nearest neighbor algorithm was used for propensity score matching with a 2:1 ratio. RESULTS: After propensity score matching, we included 45 patients from the linezolid group and 90 patients from the SPT group. Leading SAB sources were catheter related (49.6%), unknown origin (20.0%), and skin and soft tissue (17.0%). We observed no difference in 90-day relapse between the linezolid group and the SPT group (2.2% vs 4.4% respectively; P = .87). No statistically significant difference was observed in 30-day all-cause mortality between the linezolid group and the SPT group (2.2% vs 13.3%; P = .08). The median length of hospital stay after onset was 8 days in the linezolid group and 19 days in the SPT group (P < .01). No drug-related events leading to discontinuation were noted in the linezolid group. CONCLUSIONS: Treatment of SAB in selected low-risk patients with an oral switch to linezolid between days 3 and 9 of treatment until completion yielded similar clinical outcomes as SPT, allowing earlier discharge from the hospital.

Acute spinal implant infection treated with debridement: does extended antibiotic treatment improve the prognosis?

The study aims to determine whether 8 weeks of antibiotics is non-inferior to 12 weeks in patients with acute deep spinal implant infection (SII). In the retrospective study of all SII cases (2009-2016), patients aged ≥ 15 years with microbiologically confirmed SII treated with debridement and implant retention were included. Whenever possible, tailored antibiotic treatment was used: rifampin/linezolid in gram-positive and quinolones in gram-negative infection. Patients were divided into short treatment course (8 weeks, ST group) and extended treatment (12 weeks, ET group). Primary outcome measure was percentage of cures at 1-year follow-up. One-hundred-twenty-four patients considered, 48 excluded based on the above criteria, leaving 76 patients, 28 ST and 48 ET. There were no differences in patient age, comorbidities, underlying pathologies, infection location, or surgery characteristics between groups. Surgery-to-debridement time was similar (18.5-day ST vs. 19-day ET; P = 0.96). Sixteen SII cases (21.1%) occurred with bloodstream infection. Pathogens found were Enterobacteriaceae (35, 46.1%), Staphylococcus aureus (29, 38.2%), coagulase-negative staphylococci (12, 15.8%), Pseudomonas aeruginosa (12, 15.8%), and Enterococcus faecalis (7, 9.2%). Twenty seven (35.5%) had polymicrobial infection. E. faecalis was more frequent in the ST group (7, 25% vs. 0; P < 0.001), and P. aeruginosa in ET (1, 3.6% vs. 11, 22.9%; P = 0.05). Five patients died of causes unrelated to SII. At 1-year follow-up, cure rates (21/26 ST, 80.8% vs. 39/45 ET, 86.7%; P = 0.52) and recurrences (2/26, 7.7% vs. 2/45, 4.4%; P = 0.62) were similar. Eight-week antimicrobial courses were not inferior to 12 weeks in patients with acute deep SII treated with prompt debridement, proper wound healing, and optimized antibiotics.

Prognosis of Clostridium difficile infection in adult oncohaematological patients: experience from a large prospective observational study.

The aim of the study is to evaluate demographics, epidemiology, clinical characteristics, treatment and outcomes of Clostridium difficile infection (CDI) in patients with and without concurrent cancer. This is a prospective cohort study of consecutive primary CDI episodes in adults (January 2006-December 2016). CDI was diagnosed on the presence of diarrhoea and positive stool testing for toxigenic C. difficile. Univariate analysis assessed differences between cancer and non-cancer patients. Risk factors of all-cause 30-day mortality were determinate using the logistic multivariable procedure. In total, 787 CDI episodes were recorded, 191 in cancer patients (median age 64, IQR 50-73). Of these, 120 (63%) had solid and 71 (37%) haematological malignancies (24 received a stem cell transplant). At the CDI diagnosis, 158 (82.7%) cancer patients had prior antibiotics and 150 (78.5%) were receiving proton pump inhibitors. Fifty-seven (80.3%) patients with haematological and 52 (43.3%) with solid malignancies were under chemotherapy at diagnosis; 25 (35.2%) with haematological and 11 (9.2%) with solid malignancies had an absolute neutrophil count < 1000/mm3. Overall, 30-day mortality was higher in cancer patients than in those without (19.2 vs. 8.6% respectively, p < 0.001); recurrence rates did not vary significantly (11.1 vs. 11%, p = 0.936). By type of neoplasm, 30-day mortality was higher in patients with haematological malignancies and solid tumours than in patients without cancer (respectively, 25.4 vs. 8.6%; p < 0.001 and 15 vs. 8.6%; p < 0.001). Our results suggest that the prognosis of CDI (30-day mortality) is poorer in patients with cancer than in those without although percentages of recurrent infection are similar in these two patient populations.

Native vertebral osteomyelitis in aged patients: distinctive features. An observational cohort study.

PURPOSE: To describe the demographic, clinical, and microbiological profile of native vertebral osteomyelitis (NVO) in aged patients as compared to that of younger patients, to identify differences that could motivate changes in clinical management. METHODS: Retrospective, observational cohort study (1990-2015) including all adult patients with microbiologically confirmed NVO divided into 2 groups: aged (≥ 65 years) vs younger (18-64 years). RESULTS: 247 patients included, 138 aged and 109 younger. Relative to younger patients, the aged had higher rates of healthcare-related infection (40.6 vs 25.7%, p = 0.014), previous known heart valve disease (29.7 vs 9.2%, p < 0.001), and concomitant infective endocarditis (38.4 vs 20.2%, p = 0.002). The groups showed similar rates of symptomatic spinal cord compression (14.5 vs 11.9%, p = 0.556) and paraspinal abscesses (62.3 vs 68.8%, p = 0.288) at presentation. There was a trend to lower spine surgery rates in the aged (11.6 vs 17.4%, p = 0.192). On univariate analysis, Staphylococcus aureus infection was associated with higher in-hospital mortality in aged (29%, OR 4.3, 95% CI 1.61-11.45). In-hospital mortality was higher among the aged (14.5 vs 6.4%, p = 0.044) as well as relapse rate due to treatment failure (3.4 vs 1%, p = 0.377). CONCLUSIONS: The findings underscore the importance of preventing healthcare-related infection and maintaining high clinical suspicion of infective endocarditis in aged NVO patients to implement proper management. S. aureus infection had a poorer prognosis in this population. As compared to younger patients, spinal surgery rates were slightly lower and overall prognosis poorer in the aged, despite similar rates of symptomatic spinal cord compression and abscesses at presentation.

The impact of deep surgical site infection on surgical outcomes after posterior adult spinal deformity surgery: a matched control study.

PURPOSE: The impact of deep surgical site infection (SSI) on surgical outcomes after adult spinal deformity (ASD) surgery is still unclear. We aimed to study the morbidity of SSI in ASD and its impact on deformity correction and functional outcome. METHODS: Prospective multicenter matched-cohort study including consecutively enrolled ASD patients. Patients developing SSI were matched to similar controls in terms of age, gender, ASA, primary or revision, extent of fusion, and use of tri-columnar osteotomies. Preoperative parameters, surgical variables, and complications were recorded. Deformity parameters and Health Related Quality of Life (HRQoL) scores were obtained preoperatively and at 6, 12, and 24 months. Independent t test and Fischer's exact test were used for comparisons. RESULTS: 444 surgical ASD patients with more than 2 years of follow-up were identified. 20 sustained an acute SSI and 60 controls were accordingly matched. No differences were observed between groups in preoperative radiological and HRQoL variables confirming comparable groups. SSI patients had longer hospital stay and more mechanical complications including proximal junctional kyphosis. Infection was associated with more unrelated complications and revisions. Deformity correction was maintained equally at the different time intervals. One death was related to SSI. SSI patients had worse overall HRQoL status at 1 year and were less likely to experience improvement. However, no significant differences were recorded thereafter. CONCLUSION: SSI significantly affects the first postoperative year after posterior ASD surgery. It is associated with more complications, unrelated revisions, and worst quality of life. However it's negative impact seems to be diluted by the second postoperative year as differences in HRQoL scores between the two groups decrease. These slides can be retrieved under Electronic Supplementary material.

Acute periprosthetic joint infection due to Fusobacterium nucleatum in a non-immunocompromised patient. Failure using a Debridement, Antibiotics + Implant retention approach.

Fusobacterium nucleatum is an obligately anaerobic gram-negative rod, a component of the microbiome of the oropharynx and the gastrointestinal and urogenital tracts, causing an array of human infections which often include periodontal pathologies. As far as we know, there are no previous publications about acute periprosthetic joint infection due to Fusobacterium sp.; we report the first case in the medical literature of an aggressive, acute knee prosthetic infection due to F. nucleatum in a non-immunocompromised patient, unsuccessfully treated with a DAIR approach (Debridement + Antibiotics + Implant Retention).

Secular trends in the epidemiology of Clostridium difficile infection (CDI) at a tertiary care hospital in Barcelona, 2006-2015: A prospective observational study.

OBJECTIVE: Describe secular trends in the epidemiology and outcome of Clostridium difficile infection (CDI) at a tertiary hospital. METHODS: All consecutive primary CDI episodes in adults (January 2006-December 2015) were included. CDI was diagnosed on the presence of diarrhoea and a positive stool test for C. difficile toxin A and/or B. To define trends, a time-series analysis was performed using yearly data on demographics, clinical characteristics, management, antimicrobial treatment, and outcome of CDI. Patients were followed-up for three months after the diagnosis. RESULTS: There were 724 CDI episodes. Over the period from 2006 to 2015, the incidence rose from 0.18 episodes/1000 admissions to 0.26 episodes (relative rate [RR] 1.43; 95%CI, 1.02-2.00; P = 0.035). Median Charlson comorbidity index increased from 2 (IQR 1-3) to 4 (IQR 2-4) (RR 1.65; 95%CI, 1.12-2.41; P = 0.005). Overall, 80.4% of patients received proton pump inhibitors (PPIs) prior to CDI, and the percentage of PPI discontinuations rose from 2.3% to 20.4% (RR 8.80; 95%CI 1.20-64.36; P = 0.006). Management of non-Clostridium antibiotics also changed: antibiotic withdrawals or switches increased from 4.2% to 29.2% (RR 7.00; 95%CI 1.68-29.15, P = 0.001). Regarding CDI treatment, the percentage of patients treated with metronidazole decreased (88.9% vs 52.6%) (RR 0.59 (0.48-0.73), P < 0.001), whereas the percentage receiving vancomycin increased (1.9% vs 32.6%) (RR 17.62 (2.47-125.49), P < 0.001). The percentages of cures, deaths, and first recurrences did not significantly change over the 10-year period. CONCLUSIONS: Changes in CDI management were associated with a stable prognosis (percentage of cures and first recurrences), even though affected patients had a greater number of comorbidities over time.

The Not-So-Good Prognosis of Streptococcal Periprosthetic Joint Infection Managed by Implant Retention: The Results of a Large Multicenter Study.

BACKGROUND.: Streptococci are not an infrequent cause of periprosthetic joint infection (PJI). Management by debridement, antibiotics, and implant retention (DAIR) is thought to produce a good prognosis, but little is known about the real likelihood of success. METHODS.: A retrospective, observational, multicenter, international study was performed during 2003-2012. Eligible patients had a streptococcal PJI that was managed with DAIR. The primary endpoint was failure, defined as death related to infection, relapse/persistence of infection, or the need for salvage therapy. RESULTS.: Overall, 462 cases were included (median age 72 years, 50% men). The most frequent species was Streptococcus agalactiae (34%), and 52% of all cases were hematogenous. Antibiotic treatment was primarily using ß-lactams, and 37% of patients received rifampin. Outcomes were evaluable in 444 patients: failure occurred in 187 (42.1%; 95% confidence interval, 37.5%-46.7%) after a median of 62 days from debridement; patients without failure were followed up for a median of 802 days. Independent predictors (hazard ratios) of failure were rheumatoid arthritis (2.36), late post-surgical infection (2.20), and bacteremia (1.69). Independent predictors of success were exchange of removable components (0.60), early use of rifampin (0.98 per day of treatment within the first 30 days), and long treatments (≥21 days) with ß-lactams, either as monotherapy (0.48) or in combination with rifampin (0.34). CONCLUSIONS.: This is the largest series to our knowledge of streptococcal PJI managed by DAIR, showing a worse prognosis than previously reported. The beneficial effects of exchanging the removable components and of ß-lactams are confirmed and maybe also a potential benefit from adding rifampin.

[Evaluation of clinical evidence for dalbavancin]. / Evaluación de la evidencia clínica con dalbavancina.

Gram-positive infections are currently a therapeutic challenge because of the emergence of strains resistant to first-line antibiotics. Consequently, in the last few years, new antibiotics have been developed with activity against multiresistant Gram-positive bacteria, including methicillin-resistant Staphylococcus aureus and strains with intermediate sensitivity to vancomycin. Among the new antibiotics approved for the treatment of these microorganisms, dalbavancin is a semisynthetic lipoglycopeptide derived from teicoplanin, but has a superior efficacy profile to the latter. Studies published to date have confirmed the efficacy, safety and tolerability of dalbavancin in the treatment of skin and soft tissue infections caused by Gram-positive microorganisms sensitive to this drug and position it as a therapeutic option in Gram-positive catheter-related sepsis. Dalbavancin has an excellent safety profile and pharmacokinetics that allow its intravenous administration in a single weekly dose, making it a therapeutic option for outpatient use. Dalbavancin could also be an attractive alternative for patients requiring prolonged antibiotic therapy, with the aim of avoiding the need for a permanent intravenous line and its associated risks, such as infection and/or septic thrombophlebitis.

Executive summary of the diagnosis and treatment of urinary tract infection: Guidelines of the Spanish Society of Clinical Microbiology and Infectious Diseases (SEIMC).

Most urinary tract infections (UTI) are uncomplicated infections occurring in young women. An extensive evaluation is not required in the majority of cases, and they can be safely managed as outpatients with oral antibiotics. Escherichia coli is by far the most common uropathogen, accounting for >80% of all cases. Other major clinical problems associated with UTI include asymptomatic bacteriuria, and patients with complicated UTI. Complicated UTIs are a heterogeneous group associated with conditions that increase the risk of acquiring infection or treatment failure. Distinguishing between complicated and uncomplicated UTI is important, as it influences the initial evaluation, choice, and duration of antimicrobial therapy. Diagnosis is especially challenging in the elderly and in patients with in-dwelling catheters. The increasing prevalence of resistant uropathogens, including extended-spectrum ß-lactamases and carbapenemase-producing Enterobacteriaceae, and other multidrug-resistant Gram-negative organisms further compromises treatment of both complicated and uncomplicated UTIs. The aim of these Clinical Guidelines is to provide a set of recommendations for improving the diagnosis and treatment of UTI.

Potential Use of Fosfomycin-Tromethamine for Treatment of Recurrent Campylobacter Species Enteritis.

We report 2 cases of recurrent Campylobacter coli enteritis caused by macrolide- and fluoroquinolone-resistant strains in 2 patients with hypogammaglobulinemia, successfully treated with a prolonged course of fosfomycin-tromethamine with no side effects. Fosfomycin-tromethamine may be a feasible alternative therapy for recurrent enteritis caused by Campylobacter species resistant to first-line drugs.