Executive Summary: State-of-the-Art Review: Evaluation and Management of Pelvic Osteomyelitis in Stage IV Pressure Injuries: A Multidisciplinary Collaborative Approach.

Managing pelvic osteomyelitis (POM) in the setting of stage IV pressure injuries requires multidisciplinary evaluation as well as patient and caregiver engagement and is complicated by the lack of high-evidence data to guide best practices. In this review, we describe our approach to pressure injury and POM evaluation and management through multidisciplinary collaboration and highlight areas of future research that are necessary to enhance patient outcomes, reduce healthcare costs, and improve the quality of life of those affected by POM.

Evaluation and Management of Pelvic Osteomyelitis in Stage IV Pressure Injuries: A Multidisciplinary Collaborative Approach.

Managing pelvic osteomyelitis (POM) in the setting of stage IV pressure injuries requires multidisciplinary evaluation as well as patient and caregiver engagement and is complicated by the lack of high-evidence data to guide best practices. In this review, we describe our approach to pressure injury and POM evaluation and management through multidisciplinary collaboration and highlight areas of future research that are necessary to enhance patient outcomes, reduce healthcare costs, and improve the quality of life of those affected by POM.

Rifampin Based Therapy for Patients With Staphylococcus aureus Native Vertebral Osteomyelitis: A Systematic Review and Meta-analysis.

BACKGROUND: Native vertebral osteomyelitis (NVO) caused by Staphylococcus aureus is associated with high risk of treatment failure and increased morbidity. The role of rifampin-based therapy for the treatment of this condition is controversial. The goal of this systematic review and meta-analysis is to explore the efficacy and safety of rifampin-based therapy for the treatment of S. aureus NVO. METHODS: We searched Cochrane, Embase, Medline, Scopus, and Web of Science databases for studies published up to May 2023, focusing on adults with NVO treated with or without rifampin-containing regimens. A random-effects model meta-analysis estimated relative risks and risk difference with 95% confidence intervals (CI). RESULTS: Thirteen studies (2 randomized controlled trials and 11 comparative cohort studies), comprising 244 patients with S. aureus NVO who received rifampin and 435 who did not, were analyzed. Meta-analysis showed that rifampin-based regimens were associated with lower risk of clinical failure (risk difference, -14%; 95% CI, -19% to -8%; P < .001; I2 = 0%; relative risk, 0.58; 95% CI, .37-.92, P = .02, I2 = 21%). Only 1 study reported on adverse events. All studies had a high or uncertain risk of bias, and the certainty of evidence was rated as very low. CONCLUSIONS: Adjunctive rifampin therapy might be associated with lower risk of S. aureus NVO treatment failure; however, the low certainty of evidence precludes drawing definitive conclusions that would alter clinical practice. A randomized trial is necessary to corroborate these findings.

The utility of disc space and vertebral body specimens cell count differential for the diagnosis of native vertebral osteomyelitis: a prospective cohort study.

BACKGROUND: Diagnostic methods for native vertebral osteomyelitis (NVO) often yield inconclusive results. Image-guided spine biopsies for culture are specific but diagnose NVO in only 50% of cases. Pre-exposure to antimicrobials further reduces diagnostic yield. Our study assesses the value of neutrophil percentage in disc space fluid and vertebral body (DS/VB) samples for diagnosing NVO. METHODS: Adults referred for spine biopsy at Mayo Clinic from August 2022 to September 2023 were consented and enrolled at the time of biopsy. Following routine specimen collection, the biopsy needle was rinsed in saline into an EDTA tube for cell analysis. NVO diagnosis required organism identification in spine tissue or blood and/or positive histopathology, and consistent symptoms and imaging. RESULTS: Sixty-eight patients were prospectively enrolled, comprising 14 with NVO and 54 with alternative diagnoses. The median biopsy sample polymorphonuclear (PMN) percentage for NVO patients was 80.5% (IQR 72.5-85.2), compared to 64.5% (IQR 54.0-69.0) for those without NVO (p < 0.001). Nine (64.3%) NVO patients received antibiotics within 10 days prior to spine biopsy. As a continuous measure, PMN differential showed a moderately strong ability in classifying NVO status with an area under ROC curve of 0.795; an optimal point on the curve of 71.5% corresponded to a sensitivity of 78.6%, specificity of 79.6%, negative predictive value of 93.5% and positive predictive value of 50.0%. CONCLUSION: PMN differential in DS/VB biopsies may serve as an effective diagnostic tool in the evaluation of patients with NVO particularly in ambiguous cases with an initially negative spine biopsy. Future efforts will aim to implement these findings within routine clinical practice.

Do quantitative levels of antispike-IgG antibodies aid in predicting protection from SARS-CoV-2 infection? Results from a longitudinal study in a police cohort.

In a COVID-19 sero-surveillance cohort study with predominantly healthy and vaccinated individuals, the objectives were (i) to investigate longitudinally the factors associated with the quantitative dynamics of antispike (anti-S1) IgG antibody levels, (ii) to evaluate whether the levels were associated with protection from SARS-CoV-2 infection, and (iii) to assess whether the association was different in the pre-Omicron compared with the Omicron period. The QuantiVac Euroimmun ELISA test was used to quantify anti-S1 IgG levels. The entire study period (16 months), the 11-month pre-Omicron period and the cross-sectional analysis before the Omicron surge included 3219, 2310, and 895 reactive serum samples from 949, 919, and 895 individuals, respectively. Mixed-effect linear, mixed-effect time-to-event, and logistic regression models were used to achieve the objectives. Age and time since infection or vaccination were the only factors associated with a decline of anti-S1 IgG levels. Higher antibody levels were significantly associated with protection from SARS-CoV-2 infection (0.89, 95% confidence interval [CI] 0.82-0.97), and the association was higher during the time period when Omicron was predominantly circulating compared with the ones when Alpha and Delta variants were predominant (adjusted hazard ratio for interaction 0.66, 95% CI 0.53-0.84). In a prediction model, it was estimated that >8000 BAU/mL anti-S1 IgG was required to reduce the risk of infection with Omicron variants by approximately 20%-30% for 90 days. Though, such high levels were only found in 1.9% of the samples before the Omicron surge, and they were not durable for 3 months. Anti-S1 IgG antibody levels are statistically associated with protection from SARS-CoV-2 infection. However, the prediction impact of the antibody level findings on infection protection is limited.

Utility of Follow-up Coronavirus Disease 2019 (COVID-19) Antigen Tests After Acute Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection Among Healthcare Personnel.

We report the utility of rapid antigen tests (RAgT) in a cohort of US healthcare personnel with coronavirus disease 2019 (COVID-19) infection who met symptom criteria to return to work at day 5 or later of isolation. In total, 11.9% of initial RAgT were negative. RAgT can be helpful to guide return to work decisions.

Impact of the Coronavirus Disease 2019 (COVID-19) Vaccine on Asymptomatic Infection Among Patients Undergoing Preprocedural COVID-19 Molecular Screening.

BACKGROUND: Several vaccines are now available under emergency use authorization in the United States and have demonstrated efficacy against symptomatic COVID-19. Vaccine impact on asymptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is largely unknown. METHODS: We conducted a retrospective cohort study of consecutive, asymptomatic adult patients (n = 39 156) within a large US healthcare system who underwent 48 333 preprocedural SARS-CoV-2 molecular screening tests between 17 December 2020 and 8 February 2021. The primary exposure of interest was vaccination with ≥1 dose of an mRNA COVID-19 vaccine. The primary outcome was relative risk (RR) of a positive SARS-CoV-2 molecular test among those asymptomatic persons who had received ≥1 dose of vaccine compared with persons who had not received vaccine during the same time period. RR was adjusted for age, sex, race/ethnicity, patient residence relative to the hospital (local vs nonlocal), healthcare system regions, and repeated screenings among patients using mixed-effects log-binomial regression. RESULTS: Positive molecular tests in asymptomatic individuals were reported in 42 (1.4%) of 3006 tests and 1436 (3.2%) of 45 327 tests performed on vaccinated and unvaccinated patients, respectively (RR, .44; 95% CI, .33-.60; P < .0001). Compared with unvaccinated patients, risk of asymptomatic SARS-CoV-2 infection was lower among those >10 days after the first dose (RR, .21; 95% CI, .12-.37; P < .0001) and >0 days after the second dose (RR, .20; 95% CI, .09-.44; P < .0001) in the adjusted analysis. CONCLUSIONS: COVID-19 vaccination with an mRNA-based vaccine showed a significant association with reduced risk of asymptomatic SARS-CoV-2 infection as measured during preprocedural molecular screening. Results of this study demonstrate the impact of the vaccines on reduction in asymptomatic infections supplementing the randomized trial results on symptomatic patients.

Clinical Presentation and Outcomes of Pregnant Women With Coronavirus Disease 2019: A Systematic Review and Meta-analysis.

BACKGROUND: Descriptions of coronavirus disease 2019 (COVID-19) have focused on the nonpregnant adult population. This study aims to describe the clinical characteristics and perinatal outcomes of COVID-19 in pregnancy. METHODS: We searched databases from December 2019 to 30 April 2020. Eligible studies reported clinical characteristics, radiological findings, and/or laboratory testing of pregnant women during infection. Data were pooled across studies using a random-effects model. RESULTS: Twenty-four studies (136 women) were included. The most common symptoms were fever (62.9%) and cough (36.8%). Laboratory findings included elevated C-reactive protein (57%) and lymphocytopenia (50%). Ground-glass opacity was the most common radiological finding (81.7%). Preterm birth rate was 37.7% and cesarean delivery rate was 76%. There was 1 maternal death. There were 2 fetal COVID-19 cases. CONCLUSIONS: The clinical picture in pregnant women with COVID-19 did not differ from the nonpregnant population; however, the rate of preterm birth and cesarean delivery are considerably higher than international averages.

Effectiveness of Messenger RNA Coronavirus Disease 2019 (COVID-19) Vaccines Against Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection in a Cohort of Healthcare Personnel.

In a large cohort of United States healthcare personnel without prior coronavirus disease 2019 (COVID-19) infection, 94 382 doses of messenger RNA (mRNA) COVID-19 vaccine were administered to 49 220 individuals. The adjusted vaccine effectiveness following 2 doses of each of the 2 available brands of mRNA vaccine exceeded 96%.

Establishing a SARS-CoV-2 (COVID-19) Drive-Through Collection Site: A Community-Based Participatory Research Partnership With a Federally Qualified Health Center.

The COVID-19 pandemic has disproportionately affected underserved and minority populations in the United States. This is partially attributable to limited access to diagnostic testing from deeply rooted structural inequities precipitating higher infection and mortality rates. We describe the process of establishing a drive-through collection site by leveraging an academic-community partnership between a medical institution and a federally qualified health center in Minnesota. Over 10 weeks, 2006 COVID-19 tests were provided to a socioeconomically disadvantaged population of racial/ethnic minorities and low-income essential workers.

Elevated Infection and Complication Rates in Patients Undergoing a Primary THA With a History of a PJI in a Prior Hip or Knee Arthroplasty: A Matched Cohort Study.

BACKGROUND: There are little data on the outcomes of primary total hip arthroplasties (THAs) in patients with a prior surgically treated hip or knee periprosthetic joint injection (PJI). The goal of this study was to compare the risk of infection in this population with matched controls. METHODS: We retrospectively reviewed 48 patients whom underwent 50 primary THAs from 2000 to 2014 with a history of a PJI in a total knee arthroplasty or contralateral THA. Thirteen patients (27%) were on chronic antibiotic suppression at the time of primary THA. Mean age was 67 years, and mean body mass index was 35 kg/m2. Mean follow-up was 6 years. We 1:3 matched (age, sex, body mass index, cemented vs cementless femoral fixation, and surgical year) these cases to 150 primary THAs. Competing risk analysis, with death as the competing risk, was performed. RESULTS: The cumulative incidence of PJI with death as a competing risk was 1.5-fold higher in the study cohort (2.0%) compared with matched controls (1.4%) (hazards ratio, 1.5; P = .75). The cumulative incidence of any infection with death as a competing risk was 2-fold higher in the study cohort (4.0%) compared with matched controls (2.1%) (hazards ratio, 2.0; P = .45). However, these were both statistically similar given the relatively small cohort. The overall complication rate, including infections and reoperations, was 17% in the study cohort. CONCLUSION: Patients undergoing a clean primary THA with a history of a total knee arthroplasty or contralateral THA PJI in another joint have a 2% and 4% risk of PJI and any infection, respectively. Moreover, nearly 1 in 5 patients experience at least 1 complication.

Early Infectious Diseases Specialty Intervention Is Associated With Shorter Hospital Stays and Lower Readmission Rates: A Retrospective Cohort Study.

Background: Intervention by infectious diseases (ID) physicians improves outcomes for inpatients in Medicare, but patients with other insurance types could fare differently. We assessed whether ID involvement leads to better outcomes among privately insured patients under age 65 years hospitalized with common infections. Methods: We performed a retrospective analysis of administrative claims data from community hospital and postdischarge ambulatory care. Patients were privately insured individuals less than 65 years old with an acute-care stay in 2014 for selected infections, classed as having early (by day 3) or late (after day 3) ID intervention, or none. Key outcomes were mortality, cost, length of the index stay, readmission rate, mortality, and total cost of care over the first 30 days after discharge. Results: Patients managed with early ID involvement had shorter length of stay, lower spending, and lower mortality in the index stay than those patients managed without ID involvement. Relative to late, early ID involvement was associated with shorter length of stay and lower cost. Individuals with early ID intervention during hospitalization had fewer readmissions and lower healthcare payments after discharge. Relative to late, those with early ID intervention experienced lower readmission, lower spending, and lower mortality. Conclusions: Among privately insured patients less than 65 years old, treated in a hospital, early intervention with an ID physician was associated with lower mortality rate and shorter length of stay. Patients who received early ID intervention during their hospital stay were less likely to be readmitted after discharge and had lower total healthcare spending.

Update on spinal epidural abscess.

PURPOSE OF REVIEW: Spinal epidural abscess (SEA) is still a rare but potentially very morbid infection of the spine. In recent years, the incidence has risen sharply but the condition remains a medical conundrum wrought with unacceptably long diagnostic delays. The outcome depends on timely diagnosis and missed opportunities can be associated with catastrophic consequences. Management and outcomes have improved over the past decade. This review focuses on risk factors and markers that can aid in establishing the diagnosis, the radiological characteristics of SEA on MRI and their clinical implications, as well as the importance of establishing clear indications for surgical decompression. RECENT FINDINGS: This once exclusively surgically managed entity is increasingly treated conservatively with antimicrobial therapy. Patients diagnosed in a timely fashion, prior to cord involvement and the onset of neurologic deficits can safely be managed without decompressive surgery with targeted antimicrobial therapy. Patients with acute cord compression and gross neurologic deficits promptly undergo decompression. The greatest therapeutic dilemma remains the group with mild neurological deficits. As failure rates of delayed surgery approach 40%, recent research is focused on predictive models for failure of conservative SEA management. In addition, protocols are being implemented with some success, to shorten the diagnostic delay of SEA on initial presentation. SUMMARY: SEA is a potentially devastating condition that is frequently missed. Protocols are put in place to facilitate early evaluation of back pain in patients with red flags with appropriate cross-sectional imaging, namely contrast-enhanced MRI. Efforts for establishing clear-cut indications for surgical decompression of SEA are underway.

A Rare Diagnosis: Recognizing and Managing Fungal Tenosynovitis of the Hand and Upper Extremity.

PURPOSE: Fungal infections involving the tenosynovium of the upper extremity are uncommon and are often misdiagnosed. This study evaluates the epidemiology, diagnosis, treatment, and outcomes of patients with fungal tenosynovitis of the upper extremity over a 20-year period. METHODS: A retrospective review of all culture-confirmed cases of fungal tenosynovitis of the upper extremity treated between 1990 and 2013 at a single institution was performed. Clinical data included patient and epidemiologic risk factors, causative fungal organism, surgical management, antimicrobial regimen, recurrence rates, and outcomes. RESULTS: There were 10 patients (9 female, 1 male) who met the inclusion criteria. The mean patient age was 60 years (range, 47-76 y). Identified pathogens included Histoplasmacapsulatum (7), Coccidioides posadasii/immitis (2), and Cryptococcus neoformans (1). Eight patients were on immunosuppressant medications at the time of diagnosis. The most common clinical presentation was subacute localized pain, swelling, and erythema consistent with tenosynovitis. The diagnosis was delayed by a median of 6 months (range, 0-48 mo). The most helpful diagnostic imaging studies included magnetic resonance imaging and ultrasound. All patients were treated with extensive surgical synovectomy and debridement. Seven patients were treated by a single surgery, whereas 3 required multiple consecutive debridements (2, 7, and 10 surgeries). The mean course of initial antimicrobial therapy was 8.2 months (range, 3-12 mo). Clinical recurrence was noted in 3 patients (30%) during a median follow-up period of 46 months (range, 7-250 mo). Both patients with Coccidioides infection incurred recurrence. CONCLUSIONS: Although uncommon, surgeons and clinicians should consider a diagnosis of fungal tenosynovitis among immunocompromised patients with signs of mild tenosynovitis and should consider operative debridement and biopsy. Although the majority of patients were successfully treated with surgical debridement and antimicrobial therapy, a recurrence rate of 30% highlights the need for close post-treatment follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Evaluation of a Genus- and Group-Specific Rapid PCR Assay Panel on Synovial Fluid for Diagnosis of Prosthetic Knee Infection.

We evaluated a genus- and group-specific PCR assay panel using 284 prosthetic knee synovial fluid samples collected from patients presenting to our institution with implant failure. Using the Musculoskeletal Infection Society diagnostic criteria, 88 and 196 samples were classified as showing prosthetic joint infection (PJI) and aseptic failure (AF), respectively. Sensitivities of the synovial fluid PCR panel and culture were 55.6% and 76.1% (P ≤ 0.001), respectively, and specificities were 91.8% and 97.4% (P = 0.016), respectively. Among the 70 subjects who had received antibiotics within the month preceding synovial fluid aspiration (48 of whom had PJI), PCR panel and synovial fluid culture sensitivities were 64.5% and 85.4%, respectively (P < 0.0001). In this group, the PCR panel detected Staphylococcus aureus in two culture-negative PJI cases. Overall, the evaluated molecular diagnostic tool had low sensitivity when applied to synovial fluid.

A retrospective study of outcomes of device-associated osteomyelitis treated with daptomycin.

BACKGROUND: Daptomycin appears well tolerated and effective for osteomyelitis treatment. However, limited data exist regarding daptomycin use for treatment of device-associated osteomyelitis (DAO). METHODS: We used a retrospective, observational database (Cubicin® Outcomes Registry and Experience [CORE® 2007-2009]) that assessed patients treated with daptomycin to evaluate the characteristics of patients with DAO, outcomes after daptomycin treatment, and safety of daptomycin in this setting. Information from 54 institutions for patients with prosthetic joint infection (PJI) and other hardware-associated osteomyelitis (OHAO) who received daptomycin from January 2007 to December 2008 with follow-up data in 2009 was collected using a standardized data collection form. RESULTS: Eighty-two patients receiving daptomycin were identified in CORE 2007-2009; 48 patients (59 %) had follow-up data. Sixty-seven percent of patients had received a previous antibiotic. Surgical intervention was similar between the 2 groups: PJI, 22 of 27 (82 %) and OHAO, 17 of 21 (81 %). However, device removal or replacement was more frequent in the PJI patients (17 of 27, 63 %) than in the OHAO patients (8 of 21, 38 %). Clinical success was reported in 22 of 27 (82 %; 95 % confidence interval [CI], 62-94 %) patients with PJI and 18 of 21 (86 %; 95 % CI, 64-97 %) patients with OHAO at follow-up (13-402 days). Adverse events occurred in 8 of 50 (16 %) patients in the safety population and did not differ by daptomycin dose. CONCLUSION: Daptomycin appeared effective and well tolerated in patients with DAO, including PJI or OHAO.

SELECTION OF ENDOCRINOLOGY SUBSPECIALTY TRAINEES: WHICH APPLICANT CHARACTERISTICS ARE ASSOCIATED WITH PERFORMANCE DURING FELLOWSHIP TRAINING?

OBJECTIVE: To determine which residency characteristics are associated with performance during endocrinology fellowship training as measured by competency-based faculty evaluation scores and faculty global ratings of trainee performance. METHODS: We performed a retrospective review of interview applications from endocrinology fellows who graduated from a single academic institution between 2006 and 2013. Performance measures included competency-based faculty evaluation scores and faculty global ratings. The association between applicant characteristics and measures of performance during fellowship was examined by linear regression. RESULTS: The presence of a laudatory comparative statement in the residency program director's letter of recommendation (LoR) or experience as a chief resident was significantly associated with competency-based faculty evaluation scores (ß = 0.22, P = .001; and ß = 0.24, P = .009, respectively) and faculty global ratings (ß = 0.85, P = .006; and ß = 0.96, P = .015, respectively). CONCLUSION: The presence of a laudatory comparative statement in the residency program director's LoR or experience as a chief resident were significantly associated with overall performance during subspecialty fellowship training. Future studies are needed in other cohorts to determine the broader implications of these findings in the application and selection process.

Factors Associated With 20-Year Cumulative Risk of Infection After Aseptic Index Revision Total Knee Arthroplasty.

BACKGROUND: The purpose of this study was to calculate the cumulative risk of periprosthetic joint infection (PJI) after aseptic index knee revisions and to identify the surgical, perioperative, and medical comorbidity risk factors associated with deep infection. METHODS: We retrospectively reviewed 1802 aseptic index revision total knee arthroplasties performed at our institution from 1970 to 2000. From this cohort, there were 60 reoperations performed for deep infection. RESULTS: The cumulative risk of infection at 1, 5, 10, and 20 years after index revision was 1%, 2.4%, 3.3%, and 5.6%, respectively. CONCLUSIONS: Male gender, use of constrained implants, increased operative times, increased Charlson Comorbidity Index, and a history of liver disease were all significantly associated with PJI. The development of cardiovascular disease, endocrine disorders, and renal disease were also associated with PJI.

Executive Summary: 2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults.

These guidelines are intended for use by infectious disease specialists, orthopedic surgeons, neurosurgeons, radiologists, and other healthcare professionals who care for patients with native vertebral osteomyelitis (NVO). They include evidence and opinion-based recommendations for the diagnosis and management of patients with NVO treated with antimicrobial therapy, with or without surgical intervention.