Two weeks versus four weeks of antibiotic therapy after surgical drainage for native joint bacterial arthritis: a prospective, randomised, non-inferiority trial.

OBJECTIVE: The optimal duration of postsurgical antibiotic therapy for adult native joint bacterial arthritis remains unknown. METHODS: We conducted a prospective, unblinded, randomised, non-inferiority study comparing either 2 or 4 weeks of antibiotic therapy after surgical drainage of native joint bacterial arthritis in adults. Excluded were implant-related infections, episodes without surgical lavage and episodes with a follow-up of less than 2 months. RESULTS: We enrolled 154 cases: 77 in the 4-week arm and 77 in the 2-week arm. Median length of intravenous antibiotic treatment was 1 and 2 days, respectively. The median number of surgical lavages was 1 in both arms. Recurrence of infection was noted in three patients (2%): 1 in the 2-week arm (99% cure rate) and 2 in the 4-week arm (97% cure rate). There was no difference in the number of adverse events or sequelae between the study arms. Of the overall 154 arthritis cases, 99 concerned the hand and wrist, for which an additional subgroup analysis was performed. In this per-protocol subanalysis, we noted three recurrences: one in the 2-week arm (97 % cure); two in the 4-week arm (96 % cure) and witnessed sequelae in 50% in the 2-week arm versus 55% in the 4-week arm, of which five (13%) and six (13%) needed further interventions. CONCLUSIONS: After initial surgical lavage for septic arthritis, 2 weeks of targeted antibiotic therapy is not inferior to 4 weeks regarding cure rate, adverse events or sequelae and leads to a significantly shorter hospital stay, at least for hand and wrist arthritis. TRIAL REGISTRATION NUMBER: NCT03615781.

The incidence of colon cancer among patients diagnosed with left colonic or sigmoid acute diverticulitis is higher than in the general population.

BACKGROUND: Considering the low incidence of colon cancer after an initial episode of colonic diverticulitis in some categories of patients, some authors suggested to exempt them from colonoscopy. However, this incidence has never been compared to that of a reference population, and predictors of cancer are still poorly investigated. We aimed to determine the 1-year incidence of colon cancer at the site of diverticulitis in patients diagnosed with left colonic or sigmoid acute diverticulitis, to compare this incidence to a reference population to state whether endoscopy is required or not, and to identify predicting factors of cancer to better target subpopulations needing that examination. METHODS: All patients admitted at the University Hospitals of Geneva for left colonic or sigmoid acute diverticulitis were included. Patients with a previous history of colon cancer or non-available for follow-up were excluded. Demographic data, haemoglobin values, and the Hinchey score were documented. This cohort was matched with the Geneva Cancer Registry to look for cancer occurrence at the site of diverticulitis within 1 year. Predictors of cancer were assessed using univariate logistic regression and the risk of cancer by comparing observed cases to a reference population using standardized incidence ratios. RESULTS: The final cohort included 506 patients. Eleven (2.2 %) had a diagnosis of cancer at the site of diverticulitis within 1 year. The mean age was significantly different between patients with cancer and others. No predictor of cancer could be identified, except a trend for an increased risk with advancing age (p = 0.067). The standardized incidence ratios showed a 44-fold increased risk of cancer among the cohort compared to the reference population. CONCLUSIONS: Colonoscopy should be continued after an initial diagnosis of left colonic or sigmoid acute diverticulitis, irrespective of the clinical or radiological presentations.

Increased risk of joint failure in hip prostheses infected with Staphylococcus aureus treated with debridement, antibiotics and implant retention compared to Streptococcus.

PURPOSE: The debridement, antibiotic and implant retention (DAIR) procedure is an option for patients with prosthetic hip joint infections for whom arthroplasty removal is problematic. Unfortunately, some of the guidelines proposed for deciding on DAIR management of arthroplasty infections fail to take into consideration the role of the infecting pathogen. While Staphylococcus aureus and streptococci are major contributors to infected hip arthroplasties, their respective contributions to treatment success or failure rates with the DAIR procedure have not been thoroughly analysed from a microbiological perspective. METHODS: This retrospective study included all patients who were hospitalised in Geneva University Hospitals between 1996 and 2012 and were initially treated with DAIR for prosthetic hip joint monomicrobial infection due to S. aureus or Streptococcus spp. The outcome of DAIR treatment was evaluated after a minimal follow-up of two years. A literature search was also performed to retrieve data from additional DAIR-treated cases in other institutions. RESULTS: In our institution, 38 DAIR-treated patients with hip arthroplasty monomicrobial infections underwent at least one surgical debridement (median two, range one to five), exchange of mobile parts and concomitant targeted antibiotic therapy for several weeks or months. A literature search identified outcome data in other institutions from 52 additional DAIR-treated cases according to our study criteria. After merging our own data with those retrieved from other reports, we found a failure rate of 21 % instead of 24 % for S. aureus-infected, DAIR-treated patients, but no failure in 14 streptococcal-infected patients. In the pooled data, the failure rate linked with S. aureus infections was significantly higher than that with Streptococcus ssp. (19/90 vs 0/14 episodes; Fisher's exact test, P = 0.07). CONCLUSIONS: DAIR-treated patients with prosthetic hip joint infections due to S. aureus tended to have worse outcomes than those infected with Streptococcus spp. The specific influence of the infecting pathogen should be considered in future guidelines and recommendations.

Shear Wave Elastography in the Diagnosis of Hand Tumours.

Diagnosis of hand tumours by conventional imaging remains difficult. Shear wave elastography (SWE) is a noninvasive method used to quantitatively assess the mechanical properties of tissues. We provide the first report of "histoelastographic" data concerning a finger tumour. Our data support the notion of ultrasound assessment using multiple parameters including morphology, elasticity, viscosity, and microflow vascularization likely contributing towards a more precise diagnosis in the future.

Native septic arthritis is not an immediate surgical emergency.

Acute native joint septic arthritis is generally considered a surgical emergency, requiring drainage within hours, including during night, weekend or holiday shifts. However, there are few data supporting the need for the disruption caused by this degree of urgency. METHODS: We performed a retrospective review of all adult patients seen in our medical center from 1997-2015 with culture-proven septic arthritis and noted the epidemiology of sequelae, and their possible association with a delay in surgical drainage. RESULTS: Of 204 septic arthritis episodes, 46 (23%) involved interdigital hand and foot joints. Large joints involved included the knee (n = 67), shoulder (48), hip (22), ankle (8), acromio-clavicular (5), elbow (4), wrist (3), and sterno-clavicular (1) regions. All patients underwent surgical drainage of the joint and received targeted systemic antibiotic therapy. Sequelae of varying severity occurred in 83 patients (41%): recurrences (n = 15); secondary arthrosis (30); persistent pain (9); Girdlestone procedure (9); arthrodesis (9); amputation (8); stiffness (8); and Chronic Regional Pain Syndrome (2). By multivariate Cox regression analysis factors did not predict sequelae included: age; treatment with systemic corticosteroids; pre-existing clinical or radiological arthropathy; total duration of antibiotic therapy; type of joint; and, number of surgical interventions. Similarly, there was no association of sequelae with the number of days of pre-hospitalization joint symptoms (hazard ratio 1.0, 95% confidence interval 0.99-1.01) or hours spent in the emergency department (HR 1.0, 0.9-1.2). Notably, patients who had joint lavage within 6 h of presentation had similar functional outcomes as those with lavage done at 6-12 h, 12-24 h, or > 24 h after presentation. CONCLUSIONS: Our data suggest that for native septic arthritis, in the absence of clinical sepsis immediate joint drainage does not appear to reduce the risk of sequelae compared with delayed drainage.