The Use of Rifampin in Total Joint Arthroplasty: A Systematic Review and Meta-Analysis of Comparative Studies.

BACKGROUND: Periprosthetic joint infection (PJI) is a devastating complication of total joint arthroplasty (TJA). Rifampin is an antibiotic with the ability to penetrate bacterial biofilms, and thus has been considered as a potentially important adjunct in the prevention and treatment of PJI. The aim of this systematic review is to evaluate and summarize the use of rifampin in TJA, particularly in the context of PJI. METHODS: A literature search of all relevant electronic databases was performed. All comparative studies assessing the use of rifampin in the context of TJA were included. Descriptive data are reported, and a meta-analysis was performed using all studies which compared the addition of rifampin to standard care in treating PJI. RESULTS: A total of 33 studies met inclusion criteria. A meta-analysis of 22 studies comparing the addition of rifampin to standard care for treating PJI found a significant reduction in failure rates (26.0% vs 35.9%; odds ratio 0.61, 95% confidence interval 0.43-0.86). The protective effect of rifampin was maintained in studies which included exchange arthroplasty as a treatment strategy, but not in studies only using an implant retention strategy. Among studies reporting adverse events of rifampin, there was a 20.5% adverse event rate. CONCLUSION: Overall, rifampin appears to confer a protective effect against treatment failure following PJI. This treatment effect is particularly pronounced in the context of exchange arthroplasty. Further high-level evidence is needed to clarify the exact indications and doses of rifampin which can most effectively act as an adjunct in the treatment of PJI. LEVEL OF EVIDENCE: Level III, Systematic Review and Meta-Analysis of Level I-III Studies.

Reducing co-administration of proton pump inhibitors and antibiotics using a computerized order entry alert and prospective audit and feedback.

BACKGROUND: Antibiotics and proton pump inhibitors (PPIs) are associated with Clostridium difficile infection (CDI). Both a computer order entry alert to highlight this association as well as antimicrobial stewardship directed prospective audit and feedback represent novel interventions to reduce the co-administration of antibiotics and PPIs among hospitalized patients. METHODS: Consecutive patients admitted to two General Internal Medicine wards from October 1, 2010 until March 31, 2013 at a teaching hospital in Toronto, Ontario, Canada were evaluated. The baseline observation period was followed by the first phase, which involved the creation of a computerized order entry alert that was triggered when either a PPI or an antibiotic was ordered in the presence of the other. The second phase consisted of the introduction of an antibiotic stewardship-initiated prospective audit and feedback strategy. The primary outcome was the co-administration of antibiotics and PPIs during each phase. RESULTS: This alert led to a significant reduction in the co-administration of antibiotics and PPIs adjusted for month and secular trends, expressed as days of therapy per 100 patient days (4.99 vs. 3.14, p < 0.001) The subsequent introduction of the antibiotic stewardship program further reduced the co-administration (3.14 vs. 1.80, p <0.001). No change was observed in adjusted monthly CDI rates per 100 patient care days between the baseline and alert cohorts (0.12 vs. 0.12, p = 0.99) or the baseline and antibiotic stewardship phases (0.12 vs. 0.13, p = 0.97). CONCLUSIONS: Decreasing the co-administration of PPIs and antibiotics can be achieved using a simple automatic alert followed by prospective audit and feedback.

Similar duration of viral shedding of the severe acute respiratory coronavirus virus 2 (SARS-CoV-2) delta variant between vaccinated and incompletely vaccinated individuals.

Among outpatients with coronavirus disease 2019 (COVID-19) due to the severe acute respiratory coronavirus virus 2 (SARS-CoV-2) δ (delta) variant who did and did not receive 2 vaccine doses at 7 days after symptom onset, there was no difference in viral shedding (cycle threshold difference 0.59, 95% CI, -4.68 to 3.50; P = .77) with SARS-CoV-2 cultured from 2 (7%) of 28 and 1 (4%) of 26 outpatients, respectively.

Current trend of antibiotic prescription and management for peritonsillar abscess: A cross-sectional study.

OBJECTIVE: There are no consensus guidelines for managing peritonsillar abscess (PTA) despite its prevalence. In order to devise best practice guidelines, current practice patterns must first be established. METHODS: This was a cross-sectional study, surveying Otolaryngology-Head & Neck Surgery trainees (residents and fellows) and consultant (academic and community). The primary outcome was the type and duration of outpatient antibiotic prescription. Secondary outcomes included differences in workup, management, prescription, and follow-up. RESULTS: There were 57 respondents to the survey; 24 (42%) trainees (residents/fellows) and 33 (58%) consultants. On average, each respondent managed an average of 15.2 (SD 11.2) PTAs within the last year. All respondents prescribed oral antibiotics, with amoxicillin-clavulanic acid being the most common (61%). Trainees prescribed amoxicillin-clavulanic acid more often than consultants (n = 21, 88% vs n = 14, 42%, P = .0084), respectively. Duration of antibiotic therapy ranged from 5 to 14 days. Most commonly, a 10-day course of antibiotics was prescribed (n = 31, 54%). Regarding the management of PTAs, a majority of respondents requested blood work (n = 39, 68%), performed needle aspiration (n = 42, 72%) and performed incision and drainage (n = 52, 91%). Culture and sensitivity of the aspirate/drainage fluid was frequently performed (n = 41, 72%). Patients were often provided non-opioid analgesics (n = 46, 81%), but more than half still received prescription opioids (n = 36, 63%). The majority of clinicians arranged for follow-up (n = 42, 74%), most often with Otolaryngology - Head & Neck Surgery (n = 27, 64%), with an average follow-up of 12.5 (SD 8.2) days. CONCLUSION: We found heterogeneity in the management of PTAs, with variability in the outpatient antibiotic prescription. This study highlighted the wide range of management strategies employed along with differences in workup, investigation, post-discharge analgesic prescription, and follow-up arrangements. LEVEL OF EVIDENCE: 5.

Identification of prosthetic hip and knee joint infections using administrative databases-A validation study.

OBJECTIVE: To determine whether combinations of diagnosis and procedures codes can improve the detection of prosthetic hip and knee joint infections from administrative databases. DESIGN: We performed a validation study of all readmissions from January 1, 2010, until December 31, 2016, following primary arthroplasty comparing the diagnosis and procedure codes obtained from an administrative database based upon the International Classification of Disease, Tenth Revision (ICD-10) to the reference standard of chart review. SETTING: Four tertiary-care hospitals in Toronto, Canada, from 2010 to 2016. PARTICIPANTS: Individuals who had a primary arthroplasty were identified using procedure codes. INTERVENTION: Chart review of readmissions identified the presence of a prosthetic joint infection and, if present, the surgical procedure performed. RESULTS: Overall, 27,802 primary arthroplasties were performed. Among 8,844 readmissions over a median follow-up of 669 days (interquartile range, 256-1,249 days), a PJI was responsible for or present in 586 of 8,844 (6.6%). Diagnosis codes alone exhibited a sensitivity of 0.88 (95% CI, 0.85-0.92) and positive predictive value (PPV) of 0.78 (95% CI, 0.74-0.82) for detecting a PJI. Combining a PJI diagnosis code with procedure codes for an arthroplasty and the insertion of a peripherally inserted central catheter improved detection: sensitivity was 0.92 (95% CI, 0.88-0.94) and PPV was 0.78 (95% CI, 0.74-0.82). However, procedure codes were unable to identify the specific surgical approach to PJI treatment. CONCLUSIONS: Compared to PJI diagnosis codes, combinations of diagnosis and procedure codes improve the detection of a PJI in administrative databases.

Detection of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) in outpatients: A multicenter comparison of self-collected saline gargle, oral swab, and combined oral-anterior nasal swab to a provider collected nasopharyngeal swab.

BACKGROUND: Widespread testing for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) is necessary to curb the spread of coronavirus disease 2019 (COVID-19), but testing is undermined when the only option is a nasopharyngeal swab. Self-collected swab techniques can overcome many of the disadvantages of a nasopharyngeal swab, but they require evaluation. METHODS: Three self-collected non-nasopharyngeal swab techniques (saline gargle, oral swab and combined oral-anterior nasal swab) were compared to a nasopharyngeal swab for SARS-CoV-2 detection at multiple COVID-19 assessment centers in Toronto, Canada. The performance characteristics of each test were assessed. RESULTS: The adjusted sensitivity of the saline gargle was 0.90 (95% CI 0.86-0.94), the oral swab was 0.82 (95% CI, 0.72-0.89) and the combined oral-anterior nasal swab was 0.87 (95% CI, 0.77-0.93) compared to a nasopharyngeal swab, which demonstrated a sensitivity of ˜90% when all positive tests were the reference standard. The median cycle threshold values for the SARS-CoV-2 E-gene for concordant and discordant saline gargle specimens were 17 and 31 (P < .001), for the oral swabs these values were 17 and 28 (P < .001), and for oral-anterior nasal swabs these values were 18 and 31 (P = .007). CONCLUSIONS: Self-collected saline gargle and an oral-anterior nasal swab have a similar sensitivity to a nasopharyngeal swab for the detection of SARS-CoV-2. These alternative collection techniques are cheap and can eliminate barriers to testing, particularly in underserved populations.

Sensitivity of midturbinate versus nasopharyngeal swabs for the detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

To compare sensitivity of specimens for COVID-19 diagnosis, we tested 151 nasopharyngeal/midturbinate swab pairs from 117 COVID-19 inpatients using reverse-transcriptase polymerase chain reaction (RT-PCR). Sensitivity was 94% for nasopharyngeal and 75% for midturbinate swabs (P = .0001). In 88 nasopharyngeal/midturbinate pairs with matched saliva, sensitivity was 86% for nasopharyngeal swabs and 88% for combined midturbinate swabs/saliva.

Predictors of Treatment Failure for Hip and Knee Prosthetic Joint Infections in the Setting of 1- and 2-Stage Exchange Arthroplasty: A Multicenter Retrospective Cohort.

BACKGROUND: Prosthetic hip and knee joint infections (PJIs) are challenging to eradicate despite prosthesis removal and antibiotic therapy. There is a need to understand risk factors for PJI treatment failure in the setting of prosthesis removal. METHODS: A retrospective cohort of individuals who underwent prosthesis removal for a PJI at 5 hospitals in Toronto, Canada, from 2010 to 2014 was created. Treatment failure was defined as recurrent PJI, amputation, death, or chronic antibiotic suppression. Potential risk factors for treatment failure were abstracted by chart review and assessed using a Cox proportional hazards model. RESULTS: A total of 533 individuals with prosthesis removal were followed for a median (interquartile range) of 814 (235-1530) days. A 1-stage exchange was performed in 19% (103/533), whereas a 2-stage procedure was completed in 88% (377/430). Treatment failure occurred in 24.8% (132/533) at 2 years; 53% (56/105) of recurrent PJIs were caused by a different bacterial species. At 4 years, treatment failure occurred in 36% of 1-stage and 32% of 2-stage procedures (P = .06). Characteristics associated with treatment failure included liver disease (adjusted hazard ratio [aHR], 3.12; 95% confidence interval [CI], 2.09-4.66), the presence of a sinus tract (aHR, 1.53; 95% CI, 1.12-2.10), preceding debridement with prosthesis retention (aHR, 1.68; 95% CI, 1.13-2.51), a 1-stage procedure (aHR, 1.72; 95% CI, 1.28-2.32), and infection due to Gram-negative bacilli (aHR, 1.35; 95% CI, 1.04-1.76). CONCLUSIONS: Failure of PJI therapy is common, and risk factors are not easily modified. Improvements in treatment paradigms are needed, along with efforts to reduce orthopedic surgical site infections.

Dolutegravir - a review of the pharmacology, efficacy, and safety in the treatment of HIV.

Dolutegravir is the newest integrase strand transfer inhibitor to be approved for the treatment of human immunodeficiency virus (HIV) infection. Dolutegravir is equivalent or superior to existing treatment regimens in both treatment-naïve and treatment-experienced patients including those with previous raltegravir or elvitegravir failure. The consistent efficacy coupled with excellent tolerability and infrequent drug-drug interactions makes the co-formulation of dolutegravir with two nucleotide reverse-transcriptase inhibitors an attractive treatment option. This review summarizes the pharmacokinetics, adverse event profile, and efficacy of dolutegravir in the treatment of HIV.

Elevator buttons as unrecognized sources of bacterial colonization in hospitals.

BACKGROUND: Elevators are ubiquitous and active inside hospitals, potentially facilitating bacterial transmission. The objective of this study was to estimate the prevalence of bacterial colonization on elevator buttons in large urban teaching hospitals. METHODS: A total of 120 elevator buttons and 96 toilet surfaces were swabbed over separate intervals at 3 tertiary care hospitals on weekdays and weekends in Toronto, Ontario. For the elevators, swabs were taken from 2 interior buttons (buttons for the ground floor and one randomly selected upper-level floor) and 2 exterior buttons (the "up" button from the ground floor and the "down" button from the upper-level floor). For the toilet surfaces, swabs were taken from the exterior and interior handles of the entry door, the privacy latch, and the toilet flusher. Samples were obtained using standard bacterial collection techniques, followed by plating, culture, and species identification by a technician blind to sample source. RESULTS: The prevalence of colonization of elevator buttons was 61% (95% confidence interval 52%-70%). No significant differences in colonization prevalence were apparent in relation to location of the buttons, day of the week, or panel position within the elevator. Coagulase-negative staphylococci were the most common organisms cultured, whereas Enterococcus and Pseudomonas species were infrequent. Elevator buttons had a higher prevalence of colonization than toilet surfaces (61% v. 43%, p = 0.008). CONCLUSIONS: Hospital elevator buttons were commonly colonized by bacteria, although most pathogens were not clinically relevant. The risk of pathogen transmission might be reduced by simple countermeasures.

Postoperative pneumonia in elderly patients receiving acid suppressants: a retrospective cohort analysis.

OBJECTIVE: To test whether gastric acid suppressants are associated with an increased risk of postoperative pneumonia in patients undergoing elective surgery. DESIGN: Population-wide retrospective cohort analysis. SETTING: Canadian acute care hospitals between 1 April 1992 and 31 March 2008. Patients Consecutive patients aged >65 years admitted for an elective operation. OUTCOME MEASURE: Postoperative pneumonia recorded in inpatient postoperative notes. RESULTS: A total of 593 265 patients were included, of whom about 21% were taking an acid suppressant (most commonly omeprazole or ranitidine). Overall, 6389 patients developed postoperative pneumonia, with a rate significantly higher for those taking acid suppressants (13 per 1000) than controls (10 per 1000), equivalent to a 30% increase in frequency (odds ratio 1.30 (95% confidence interval 1.23 to 1.38), P<0.001). However, no increase in risk was observed after adjustment for duration of surgery, site of surgery, and other confounders (odds ratio 1.02 (0.96 to 1.09), P=0.48). The general safety of acid suppressants extended to those patients prescribed proton pump inhibitors, experiencing long term treatment, receiving high doses, and undergoing high risk procedures. CONCLUSION: After adjustment for patient and surgical characteristics, acid suppressants are not associated with an increased risk of postoperative pneumonia among elderly patients admitted for elective surgery.