A Case of In Situ Phage Therapy against Staphylococcus aureus in a Bone Allograft Polymicrobial Biofilm Infection: Outcomes and Phage-Antibiotic Interactions.

Phage therapy (PT) shows promising potential in managing biofilm infections, which include refractory orthopedic infections. We report the case of a 13-year-old girl who developed chronic polymicrobial biofilm infection of a pelvic bone allograft after Ewing's sarcoma resection surgery. Chronic infection by Clostridium hathewayi, Proteus mirabilis and Finegoldia magna was worsened by methicillin-susceptible Staphylococcus aureus exhibiting an inducible Macrolides-Lincosamides-Streptogramin B resistance phenotype (iMLSB). After failure of conventional conservative treatment, combination of in situ anti-S. aureus PT with surgical debridement and intravenous antibiotic therapy led to marked clinical and microbiological improvement, yet failed to prevent a recurrence of infection on the midterm. This eventually led to surgical graft replacement. Multiple factors can explain this midterm failure, among which incomplete coverage of the polymicrobial infection by PT. Indeed, no phage therapy against C. hathewayi, P. mirabilis or F. magna could be administered. Phage-antibiotic interactions were investigated using OmniLog® technology. Our results suggest that phage-antibiotic interactions should not be considered "unconditionally synergistic", and should be assessed on a case-by-case basis. Specific pharmacodynamics of phages and antibiotics might explain these differences. More than two years after final graft replacement, the patient remains cured of her sarcoma and no further infections occurred.

Long-term outcome of surgical excision for treatment of cervicofacial granulomatous lymphadenitis in children.

PURPOSE: Granulomatous inflammation is a common cause of subacute cervicofacial lymphadenitis in children. Nontuberculous mycobacterial (NTM) infections and cat-scratch disease (CSD) are the most frequent causes. Optimal treatment, which may include surgery, antibiotic treatment or wait-and-see approach, is debatable. The goal of this study was to compare the short- and long-term outcome of various surgical procedures. METHODS: Case series with a chart review of all children treated by surgical excision of granulomatous lymph nodes in the cervicofacial area from 2000 to 2016 at two tertiary care centers. RESULTS: Forty patients were included in this study. The median age at first symptoms was 3.7 years (13 months-14 years). Mean follow-up was 5.8 years (6 months-15.3 years). 25 patients fit with diagnosis of NTM infection, 6 with CSD while diagnosis remained uncertain in 9 patients. The primary surgical procedure consisted of total excision (n = 27), incision/drainage (n = 9) or incomplete excision (n = 4). None of the patients treated by primary complete excision needed further intervention contrary to the group of patients with incomplete surgical procedures where additional surgical management was required in 54%. At follow-up, all patients were healthy without evidence of recurrence. CONCLUSION: We advocate early surgical intervention with complete excision to reach quick resolution and reduce the need for additional surgery. The long-term outcome was favorable.

Concordance between nurse-reported quality of care and quality of care as publicly reported by nurse-sensitive indicators.

BACKGROUND: Nurse-sensitive indicators and nurses' satisfaction with the quality of care are two commonly used ways to measure quality of nursing care. However, little is known about the relationship between these kinds of measures. This study aimed to examine concordance between nurse-sensitive screening indicators and nurse-perceived quality of care. METHODS: To calculate a composite performance score for each of six Dutch non-university teaching hospitals, the percentage scores of the publicly reported nurse-sensitive indicators: screening of delirium, screening of malnutrition, and pain assessments, were averaged (2011). Nurse-perceived quality ratings were obtained from staff nurses working in the same hospitals by the Dutch Essentials of Magnetism II survey (2010). Concordance between the quality measures was analyzed using Spearman's rank correlation. RESULTS: The mean screening performances ranged from 63% to 93% across the six hospitals. Nurse-perceived quality of care differed significantly between the hospitals, also after adjusting for nursing experience, educational level, and regularity of shifts. The hospitals with high-levels of nurse-perceived quality were also high-performing hospitals according to nurse-sensitive indicators. The relationship was true for high-performing as well as lower-performing hospitals, with strong correlations between the two quality measures (rS = 0.943, p = 0.005). CONCLUSIONS: Our findings showed that there is a significant positive association between objectively measured nurse-sensitive screening indicators and subjectively measured perception of quality. Moreover, the two indicators of quality of nursing care provide corresponding quality rankings. This implies that improving factors that are associated with nurses' perception of what they believe to be quality of care may also lead to better screening processes. Although convergent validity seems to be established, we emphasize that different kinds of quality measures could be used to complement each other, because various stakeholders may assign different values to the quality of nursing care.

Feasibility and effectiveness of early initiation of combination antiretroviral therapy in HIV-infected infants in a government clinic of Kwazulu-Natal, South Africa.

A recent randomized trial showed dramatic improvement in survival of HIV-infected infants receiving early combination antiretroviral therapy (cART). However, few data are available for resource-limited settings. Therefore we conducted a chart review of HIV-infected infants initiated on cART between 2005 and 2008. Of 129 treated infants, 94 completed 6 months, 62 completed 12 months, and 39 completed 18 months of cART. Median age at initiation of cART was 8.6 months (range 2.1-11.9) and 77.2% had advanced disease. Undetectable VL was found in 78.8% of children who reached 18 months of treatment. CD4% increased from a median of 15.4% at baseline to 33.1% at 18 months. Weight for age Z-score increased from a mean ± SD of -2.7 ± 1.97 to 0.02 ± 1.10 at 18 months. Findings show favourable response to cART in HIV-infected infants outside a research environment, despite initial advanced disease. Efforts should be made to initiate cART as early as possible.