Severe skin and soft tissue infection in cohort patients admitted in a teaching hospital in Belgium: identification of risk factors for surgery.

BACKGROUND: Necrotizing soft tissue infections (NSTIs) are associated with significant mortality if not promptly diagnosed and surgically treated. AIM: This study aims to compare patients with severe skin and soft tissue infection treated with or without a surgical intervention and to identify risk factors that can predict the need for early surgery. METHODS: Demographics, clinical, laboratory, Risk Indicator for Necrotizing Fasciitis (LRINEC) and imaging results were retrospectively collected. RESULTS: There were 91 non-NSTI (group 1), 26 NSTI who were operated (group 2) and eight suspected NSTI who were not operated (group 3). In the multivariate analysis, skin necrosis, tachycardia, CRP value and hyperglycemia were predictive for surgery. A performance analysis revealed AUC of 0.65 (95%CI: 0.52-0.78) as to the LRINEC score for the use of surgery. The AUC for a predictive model associating four variables (heart rate, skin necrosis, CRP and glycemia at admission) was 0.71 (95%CI: 0.59-0.84). In terms of outcome, the median length of stay (LOS) was statistically higher in group 2 vs. group 1 (seven days (5-15) vs. 34 days (20-42), p < .001) and in group 2 vs. group 3 (34 days (20-42) vs. 14 days (11-19), p = .005). The overall in-hospital mortality at 30 days was 3.2% and did not statistically differ between the three groups. CONCLUSIONS: Although the LRINEC score performed well in predicting surgery, the AUC of a model combining four predictive variables (glycemia, skin necrosis, CRP and heart rate) was superior. Further research is needed to validate this model.

Are C-reactive protein (CRP) and neutrophil to lymphocyte ratio (NLR) predictive markers of successful two-stage prosthetic joint infection management?

The treatment of prosthetic joint infections (PJI) regularly involves a two-stage surgical strategy. The second stage is generally performed when the surgeon estimates that the infection is under control based on either the treatment length or clinical and biological data. We have raised the question whether standardization of C-reactive protein (CRP) and neutrophil to lymphocyte ratio (NLR) values could be either indicative of infection control or predictive of infection recurrence. This was an analytical retrospective and monocentric cross-sectional observational study. The CRP and NLR values were recorded prior to the second-stage surgery in a sample of 100 patients who underwent a two-stage revision arthroplasty following a PJI, and these values were correlated with the absence of infectious recurrence within a 2-year follow-up. The statistical analysis consisted of evaluating the diagnostic validity of each marker, first individually, and then in combination. CRP was shown associated with a 68% sensitivity, 40% specificity, 27% positive predictive value (PPV), and 79% negative predictive value (NPV). The ROC curve was 51.1%. The NLR displayed a 12% sensitivity, 89% specificity, 27% PPV, and 75% NPV. The ROC curve was 47.9%. The combination of the two markers did not fundamentally improve the statistical results, with only a 43% concordance of the two markers, 27% sensitivity, 84% specificity, 37% PPV, and 77% NPV. Measuring CRP and NLR values, either individually or in combination, before the second-stage revision arthroplasty did not turn out to be predictive of either infection recurrence or cure within two years of follow-up. Therefore, an absolute test is still lacking, which would enable us to predict without failure the absence of control or the control of a PJI before or after second-stage revision. Level of evidence: Level III, retrospective cross-sectional study.

PMMA-cement anterior column reconstruction in surgical treatment of spondylodiscitis.

Introduction and research question: This paper explains how antibiotic loaded cement can be used in surgical treatment of spondylodiscitis to reconstruct the anterior column of the spine. Material and methods: 35 consecutive surgical procedures performed for spondylodiscitis were collected over a 11-year period and charts were reviewed. Most infections were caused mainly by staphylococcus spp (n = 16), streptococcus spp (n = 8) and pseudomonas spp (n = 4). Most patients had long standing but unsuccessful antibiotic therapy (median 42 days). Other indications included instability, neurologic deficit, abscess, and patients were generally in very poor medical condition. Results: Anterior debridement was followed by a partial cavity filling with surgical high viscosity PMMA cement in all cases. Cement was a high viscosity gentamycin loaded cement, that was placed in the cavity created by debridement under the direct eye control. In 25 cases, a part of the cavity was filled with freeze dried cancellous bone allograft rehydrated in rifampicin. Spine was further stabilized with an anterior plate in 15 cases, with short (+1/+1) posterior instrumentation in 5 cases, and a long (≥ +2/+2) posterior instrumentation in 11 cases. In four patients, spine was left un-instrumented. Immediate, unrestricted mobilization was always authorized after surgery. None of the patients were reoperated neither for mechanical failure nor for infection relapse. Conclusion: This report supports the idea that surgical bone cement is an efficient gap filler when used through anterior approach. For small as well as for large defects, it can help to reconstruct the anterior column and locally control the infection in combination with additional stabilization and optimal intravenous and oral antibiotic treatment.

Safety of systemic anti-cancer treatment in oncology patients with non-severe COVID-19: a cohort study.

BACKGROUND: The viral pandemic coronavirus disease 2019 (COVID-19) has disrupted cancer patient management around the world. Most reported data relate to incidence, risk factors, and outcome of severe COVID-19. The safety of systemic anti-cancer therapy in oncology patients with non-severe COVID-19 is an important matter in daily practice. METHODS: ONCOSARS-1 was a single-center, academic observational study. Adult patients with solid tumors treated in the oncology day unit with systemic anti-cancer therapy during the initial phase of the COVID-19 pandemic in Belgium were prospectively included. All patients (n = 363) underwent severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) serological testing after the first peak of the pandemic in Belgium. Additionally, 141 of these patients also had a SARS-CoV-2 RT-PCR test during the pandemic. The main objective was to retrospectively determine the safety of systemic cancer treatment, measured by the rate of adverse events according to the Common Terminology Criteria for Adverse Events, in SARS-CoV-2-positive patients compared with SARS-CoV-2-negative patients. RESULTS: Twenty-two (6%) of the 363 eligible patients were positive for SARS-CoV-2 by RT-PCR and/or serology. Of these, three required transient oxygen supplementation, but none required admission to the intensive care unit. Hematotoxicity was the only adverse event more frequently observed in SARS-CoV-2 -positive patients than in SARS-CoV-2-negative patients: 73% vs 35% (P < 0.001). This association remained significant (odds ratio (OR) 4.1, P = 0.009) even after adjusting for performance status and type of systemic treatment. Hematological adverse events led to more treatment delays for the SARS-CoV-2-positive group: 55% vs 20% (P < 0.001). Median duration of treatment interruption was similar between the two groups: 14 and 11 days, respectively. Febrile neutropenia, infections unrelated to COVID-19, and bleeding events occurred at a low rate in the SARS-CoV-2-positive patients. CONCLUSION: Systemic anti-cancer therapy appeared safe in ambulatory oncology patients treated during the COVID-19 pandemic. There were, however, more treatment delays in the SARS-CoV-2-positive population, mainly due to a higher rate of hematological adverse events.

Clinical characteristics and humoral immune response in healthcare workers with COVID-19 in a teaching hospital in Belgium.

BACKGROUND: Healthcare workers (HCWs) are at high risk of acquiring COVID-19 and could play a role in nosocomial transmission. Since 4th February 2020, Belgian Health authorities reported more than 90,568 cases, of which 8.3% were HCWs. Data on clinical characteristics, sources of infection and humoral immune response of HCWs with COVID-19 remain scarce. AIM: To analyse the clinical characteristics, humoral immune response, sources of contamination, and outcomes among HCWs with COVID-19. METHODS: This retrospective study included 176 HCWs with laboratory-confirmed COVID-19 in a teaching hospital in Belgium. Between 1st March and 31st May 2020, all HCWs with symptoms suspected of COVID-19 were tested by reverse transcription polymerase chain reaction on a nasopharyngeal swab. Serological testing was performed between 55 and 137 days after the onset of symptoms. FINDINGS: Median age was 40.8 years and 75% were female. Median delay between onset of symptoms and diagnosis was 4.39 days. Most frequent symptoms were cough and headache (both 75%). Fever accounted for 68.7%. Most represented professions were nurses (42%). HCWs were mainly infected by patient contact (32.9%); 7.6% required hospitalization and 1.7% were admitted to the intensive care unit. Unfortunately, one HCW died (0.5%). Total antibodies were positive in 109/126 (86.5%). CONCLUSIONS: Clinical presentation of COVID-19 in HCWs does not differ from the general population. However, outcomes were more favourable with a mortality rate lower than that reported in Belgian COVID-19 patients in general (16%). The main source of infection was the hospital setting. Our positive antibodies rate was high but lower than previously reported.

Adult haemophagocytic lymphohistiocytosis: a Review.

BACKGROUND: Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disorder characterized by hyperimmune response. The mortality is high despite progress being made in the diagnosis and treatment of the disease. AIM: This review aimed to update knowledge on adult HLH pathophysiology, identifiy the numerous causes, and help clinicians make early diagnosis and initiate treatment. DESIGN AND METHODS: Using Embase, we searched relevant articles published from January 1, 2010 to October 31, 2019, with the MESH term « hemophagocytic lymphohistiocytosis; macrophagic activation syndrome, adult ¼. RESULTS: The mean age at presentation is about 50 years, with a male predominance. The most frequent disease associations are haematological diseases, viral or bacterial infections, and autoimmune diseases. The pathophysiologic mechanism is probably the combination of inherited genetic mutations and extrinsic triggers. The mortality rate is 26.5% to 74.8%. H-score is more efficient than HLH-2004 criteria to identify HLH, with diagnostic sensitivity and specificity 90% and 79%, respectively.18F-FDG PET/CT is potentially useful for detecting underlying disease and the extent of secondary HLH. Disease-specific treatment should be given as soon as possible. Treatment with corticosteroids combined or not with etoposide is the mainstay of treatment. Monoclonal antibodies and JAK pathway inhibitors show promise of being effective. CONCLUSION: In adult HLH, infectious diseases, autoimmune disease and malignancy should be suspected so that disease-specific treatment can be given promptly. Treatment with corticosteroids combined or not with etoposide is the mainstay of treatment, but new therapies show promise of being effective.

Neutrophil-to-lymphocyte ratio (NLR) distribution shows an advantage compared to C-reactive protein (CRP) for the early inflammation monitoring after total hip arthroplasty.

C-reactive protein (CRP) distribution has been used to monitor early inflammation after total hip arthroplasty (THA). Neutrophil to lymphocyte ratio (NLR) is a new and cheap inflammatory marker. This study aimed to verify whether Neutrophil to lymphocyte ratio (NLR) distribution has an advantage when compared to C-reactive protein (CRP) distribution for the inflammation monitoring after total hip arthroplasty (THA). 116 THA patients were retrospectively selected over a 2 years period. They all had available blood tests preoperatively and at postoperative days 2, 4 and 42. Median peak values were compared between CRP and NLR. The effect of demographics on CRP and NLR was tested. At days 4 and 42, 100% and 16.3% of patients had not reached normal CRP (< 10mg/L) while 56.8% and 6.8% of patients had not reached normal NLR (<5) respectively. There was no effect of demographics on NLR except for age. Older patients had higher NLR (p 0.037). NLR showed a quicker return to normal than CRP. Our results show that NLR seems to be a better marker to follow inflammation after THA than CRP.

Concordance between superficial swab and deep sampling in post-sternotomy mediastinitis: Single center experience.

OBJECTIVES: Deep sampling (DS) is the gold standard for microbiological diagnosis of post-sternotomy mediastinitis (PSM), however superficial swab (SS) are frequently performed in some centers and antibiotherapy initiated base on their results. We analysed the concordance between superficial swab and deep sampling in PSM. MATERIALS AND METHODS: We analysed retrospectively patients with a PSM between 2010 and 2014 at Saint-Luc University hospital (Belgium). We considered that there was a concordance between SS and DS when the same microorganism was found in the two sampling method in each patient. Patients were stratified in six groups according to microbiology results as Staphylococcus Aureus (SA) sensitive or resistant, coagulase negative Staphylococcus (CoNS), Gram negative bacilli (GNB), other Gram positive bacteria (GPB) and fungi. RESULTS: Thirty-six patients were included. Twenty-five men (69%) and a mean age of 66 years old. The overall concordance between SS and DS was 57%. SA and GNB showed high concordance (100% and 85.7% respectively). For the other groups the concordance was low. The sensitivity and specificity of SS was 97% and 33% respectively. The PPV and NPV of superficial swab was 96% and 50% respectively. CONCLUSION: Microbiological results from SS, even with flocked swabs, except for SA and GNB have low concordance with those obtained from deep sampling. Our data confirm that in PSM, deep sampling is the gold standard for microbiological assessment.

Difficult to treat osteoarticulars infections : Focus on Mycobacterial and Fungal infection.

Bone and joint infections are rare but often devastating. While bacteria are most commonly encountered organisms, mycobacteria and fungi are less frequent. Management of the latter is often more complex, especially in the presence of foreign material. We will increasingly be faced with mycobacterial and fungal bone infections, as medical conditions and newer therapeutics lead to more immunosuppression. In this article, we will review osteomyelitis, septic arthritis and peri-prosthetic joint infections related to mycobacteria and fungi.

First case of a dog bite wound infection caused by Streptococcus minor in human.

We report the first case of human infection caused by Streptococcus minor in a 51-year-old immunocompetent woman admitted for dog bite injuries. At present, the role of Streptococcus minor in bite wound infections is unknown. Further studies on virulence factors are needed to elucidate its pathogenicity mechanisms.

Acute pyelonephritis and renal vein thrombosis: A case report and review of the literature.

A 68-year-old female presented with a week history of fever and generalized weakness. Clinical examination, blood work and urinalysis were compatible with sepsis due to acute pyelonephritis. Urine cultures were positive for Escherichia coli and blood cultures were negative. After 5 days of antibiotic therapy with cefuroxime, inflammatory parameters (CRP level and white blood cell count) remained highly elevated. Abdominal CT scan showed right kidney pyelonephritis with renal and perirenal abscess and right renal vein thrombosis. The patient improved after percutaneous drainage of the perirenal abscess and anticoagulation treatment. She was discharged on hospital day 14.

Neutrophil-to-lymphocyte ratio (NLR) distribution shows a better kinetic pattern than C-reactive protein distribution for the follow-up of early inflammation after total knee arthroplasty.

PURPOSE: This study aimed to assess whether the neutrophil-to-lymphocyte ratio (NLR) distribution could have a better kinetic pattern than C-reactive protein (CRP) distribution to evaluate early post-operative inflammation after total knee arthroplasty (TKA). METHODS: A prospective study was performed on 587 patients. CRP and NLR were collected pre-operatively and at post-operative days 2, 4, 21 and 42. Mean peak values and distribution were compared between CRP and NLR. RESULTS: Mean CRP levels were 163, 161, 9 and 7 mg/L, respectively, at days 2, 4, 21 and 42. Mean NLR levels were 5, 3.5, 2.6 and 2.5, respectively, at days 2, 4, 21 and 42. At days 21 and 42, 20 % (102/503) and 21 % (93/433) of patients had not reached normal CRP levels. At day 21, there were 4.5 % (23/503) of patients with a NLR > 5 and 1 % (5/503) with an NLR > 10. At day 42, there were 5.5 % (24/433) of patients with an NLR > 5 and 0.7 % (3/433) with an NLR > 10. CONCLUSION: NLR has a faster normalization than CRP. It is potentially a better biomarker to follow post-operative inflammation or early infection after TKA. LEVEL OF EVIDENCE: II.

Monitoring of kidney function in HIV-positive patients.

HIV-positive patients are at increased risk of developing chronic kidney disease. Although guidelines recommend regular monitoring of renal function in individuals living with HIV, the optimal frequency remains to be defined. In this review, we discuss the renal syndromes that may be identified at an earlier stage via routine assessment of kidney function, and provide guidance in terms of the frequency of monitoring, the most useful tests to perform, and their clinical significance. Specifically, we address whether annual monitoring of kidney function is appropriate for the majority of HIV-positive patients.

Clinical features and outcome of typhoid fever and invasive non-typhoidal salmonellosis in a tertiary hospital in Belgium: analysis and review of the literature.

OBJECTIVES: Typhoid fever (TF) occurs rarely in industrialized countries because of advances in health care and improvement of drinking water. Conversely, non-typhoid salmonellosis (NTS) remains widespread, because of food contamination or asymptomatic carriage. Non-typhoid salmonellosis can be severe when becoming invasive non-typhoid salmonellosis (iNTS). Although established prognostic indicators of the two pathologies are different, direct comparisons between iNTS and TF in the literature remain scarce. The purpose of this study was to analyse and compare demographic, clinical features and outcome of hospitalized patients with TF and iNTS. METHODS: Demographic, clinical features and outcome were retrospectively analysed in a series of patients hospitalized between 2007 and 2012. RESULTS: A total of 33 patients were enrolled, including 13 with established TF and 20 with iNTS. No differences between TF and iNTS patients were observed in incidence of fever, abdominal cramps, diarrhoea, headache, nausea and vomiting and duration of antibiotic therapy (≤ 7 days in both groups). Although the clinical outcome of TF patients was identical to that of iNTS patients, including incidence of complications, length of hospitalization and mortality (1/13 (7.7%) vs 2/20 (10%), P = 0.43), comorbidities were less frequent in the TF group than in the iNTS group (2/13 vs 15/20, P = 0.003). CONCLUSION: The clinical profile and outcome of TF patients are similar to those with iNTS. Although comorbidities are more often associated with iNTS, the results of our study suggest that clinical management of these two diseases should remain similar.

Nocardia prosthetic knee infection successfully treated by one-stage exchange: case report and review.

A 64-year-old man with a history of sarcoidosis on corticosteroids and azathioprine was admitted to our hospital with complaints of worsening left knee pain and swelling for the past 3 weeks. His past medical history is also significant for severe osteoarthritis requiring a cemented total left knee arthroplasty 1 year ago. Diagnostic investigation during his hospital admission eventually led to the diagnosis of Nocardia nova knee prosthetic joint infection in the setting of a disseminated nocardiosis. He was successful treated by one-stage complete hardware exchange in conjunction with an adapted antibiotic therapy regimen (meropenem and doxycycline followed by ceftriaxone and doxycycline). Two years later, his recovery was deemed excellent.