Predictors of Treatment Success After Periprosthetic Joint Infection: 24-Month Follow up From a Multicenter Prospective Observational Cohort Study of 653 Patients.

BACKGROUND: Periprosthetic joint infection (PJI) is a devastating condition and there is a lack of evidence to guide its management. We hypothesized that treatment success is independently associated with modifiable variables in surgical and antibiotic management. METHODS: The is a prospective, observational study at 27 hospitals across Australia and New Zealand. Newly diagnosed large joint PJIs were eligible. Data were collected at baseline and at 3, 12, and 24 months. The main outcome measures at 24 months were clinical cure (defined as all of the following: alive, absence of clinical or microbiological evidence of infection, and not requiring ongoing antibiotic therapy) and treatment success (clinical cure plus index prosthesis still in place). RESULTS: Twenty-four-month outcome data were available for 653 patients. Overall, 449 patients (69%) experienced clinical cure and 350 (54%) had treatment success. The most common treatment strategy was debridement and implant retention (DAIR), with success rates highest in early postimplant infections (119 of 160, 74%) and lower in late acute (132 of 267, 49%) and chronic (63 of 142, 44%) infections. Selected comorbidities, knee joint, and Staphylococcus aureus infections were independently associated with treatment failure, but antibiotic choice and duration (including rifampicin use) and extent of debridement were not. CONCLUSIONS: Treatment success in PJI is associated with (1) selecting the appropriate treatment strategy and (2) nonmodifiable patient and infection factors. Interdisciplinary decision making that matches an individual patient to an appropriate management strategy is a critical step for PJI management. Randomized controlled trials are needed to determine the role of rifampicin in patients managed with DAIR and the optimal surgical strategy for late-acute PJI.

Clinical Characteristics, Etiology, and Initial Management Strategy of Newly Diagnosed Periprosthetic Joint Infection: A Multicenter, Prospective Observational Cohort Study of 783 Patients.

BACKGROUND: Periprosthetic joint infection (PJI) is a devastating complication of joint replacement surgery. Most observational studies of PJI are retrospective or single-center, and reported management approaches and outcomes vary widely. We hypothesized that there would be substantial heterogeneity in PJI management and that most PJIs would present as late acute infections occurring as a consequence of bloodstream infections. METHODS: The Prosthetic joint Infection in Australia and New Zealand, Observational (PIANO) study is a prospective study at 27 hospitals. From July 2014 through December 2017, we enrolled all adults with a newly diagnosed PJI of a large joint. We collected data on demographics, microbiology, and surgical and antibiotic management over the first 3 months postpresentation. RESULTS: We enrolled 783 patients (427 knee, 323 hip, 25 shoulder, 6 elbow, and 2 ankle). The mode of presentation was late acute (>30 days postimplantation and <7 days of symptoms; 351, 45%), followed by early (≤30 days postimplantation; 196, 25%) and chronic (>30 days postimplantation with ≥30 days of symptoms; 148, 19%). Debridement, antibiotics, irrigation, and implant retention constituted the commonest initial management approach (565, 72%), but debridement was moderate or less in 142 (25%) and the polyethylene liner was not exchanged in 104 (23%). CONCLUSIONS: In contrast to most studies, late acute infection was the most common mode of presentation, likely reflecting hematogenous seeding. Management was heterogeneous, reflecting the poor evidence base and the need for randomized controlled trials.

Towards elimination of tuberculosis in New Zealand.

New Zealand could be the first country in the world to eliminate tuberculosis (TB). We propose a TB elimination strategy based on the eight-point World Health Organization (WHO) action framework for low incidence countries. Priority actions recommended by the WHO include 1) ensure political commitment, funding and stewardship for planning and essential services; 2) address the most vulnerable and hard-to-reach groups; 3) address special needs of migrants and cross-border issues; 4) identify active TB and undertake screening for latent tuberculosis infection (LTBI) in recent TB contacts and selected high-risk groups, and provide appropriate treatment; 5) optimise the prevention and care of drug-resistant TB; 6) ensure continued surveillance, programme monitoring and evaluation and case-based data management; 7) invest in research and new tools; and 8) support global TB prevention, care and control. In New Zealand, central government needs to take greater responsibility for TB policy and programme governance. Urgent action is required to prevent TB in higher risk groups including Maori communities, and to enable immigration screening to detect and treat LTBI. Clinical services need to be supported to implement new guidelines for LTBI that enable better targeting of screening and shorter, safer treatment regimens. Access to WHO recommended treatment regimens needs to be guaranteed for drug-resistant TB. Better use of existing data could better define priority areas for action and assist in the evaluation of current control activities. Access to GeneXpert® MTB-RIF near the point of care and whole genome sequencing nationally would greatly improve clinical and public health management through early identification of drug resistance and outbreaks. New Zealand already has a world-class TB research community that could be better deployed to assist high-incidence countries through research and training.

Infectious pulmonary tuberculosis in a New Zealand cancer centre.

This report details the investigation of oncology and haematology patients, as well as cancer centre staff, friends and family who were exposed to an oncology patient with reactivated pulmonary tuberculosis (TB) in a New Zealand cancer centre. A total of 46 patients, seven staff members and 14 family and friends were identified as being exposed to the index case of TB (Mr K). These people were screened for TB infection by the use of a symptom questionnaire, Qiagen QuantiFeron (QFT)® Gold Plus test and, if potentially immunocompromised, a chest x-ray (CXR). There were no confirmed secondary cases of TB in any of the groups screened for infection, but surveillance for signs and symptoms of TB disease in those with significant risk is ongoing. In this article we discuss the public health response to TB in a cancer centre and potential preventative strategies for the future.

Epidural abscess caused by Streptobacillus moniliformis.

We present an interesting case of a patient who developed an epidural abscess caused by Streptobacillus moniliformis. This is the first report in the medical literature of a spinal epidural abscess associated with this organism. Diagnosis of S. moniliformis infection requires a high degree of suspicion, and a delay may be inevitable when a relevant clinical history is lacking.

Effectiveness of cotrimoxazole prophylaxis on mortality in adults with tuberculosis in rural South Africa.

BACKGROUND: Adults with dual tuberculosis (TB) and HIV infection have a poor outcome. Studies in West Africa suggest that cotrimoxazole prophylaxis may reduce this mortality. OBJECTIVE: To evaluate the effectiveness of cotrimoxazole in reducing mortality in adults with active TB, irrespective of HIV status, in a high prevalence setting. DESIGN: Cohort study using historical controls. METHODS: Adults treated for TB between 1998 and 2000 were traced and vital status at 6 months ascertained (2004: control group). All adults starting treatment for TB between June 2001 and June 2002 were offered cotrimoxazole prophylaxis 960 mg once daily for 6 months during TB treatment irrespective of HIV status (1321: intervention group). Mortality, adverse reactions and adherence were compared between intervention and control groups. RESULTS: HIV seroprevalence in patients with TB at the start of the intervention was estimated to be 78%. Mortality at 6 months was 29% lower in the group given cotrimoxazole than in the control group. The number needed to treat to prevent one death during the period of TB treatment was 24. The benefit was seen across all types of TB but was only evident in new patients; patients being retreated had similar outcomes in both groups. Adverse events were infrequent and minor, with only two participants having treatment stopped for this reason. CONCLUSION: Cotrimoxazole prophylaxis for all adults with TB, irrespective of HIV status, in an area of high HIV seroprevalence may be a feasible, safe and effective way to reduce mortality for the duration of treatment.

HIV infection as a cofactor for severe falciparum malaria in adults living in a region of unstable malaria transmission in South Africa.

BACKGROUND: Malaria and HIV are two of the most important diseases facing Africa. It remains uncertain whether HIV-related immunosuppression adversely affects the clinical outcome of malaria. OBJECTIVE: To measure the association between HIV status and outcome from malarial infection in adults living in a region of unstable malaria transmission. DESIGN: Observational cohort study. SETTING: Four community clinics and the Government hospital in Hlabisa district, KwaZulu-Natal, South Africa; a region of high HIV prevalence. METHODS: Consecutive febrile adults were screened for malaria with a rapid antigen test. Those with malaria provided blood spots for HIV testing, a thick blood film for confirmation of malaria and clinical data. Outcome was established following management according to South African government guidelines. RESULTS: Malaria was microscopically confirmed in 613. HIV prevalence was 29.9% (180/613); 110 (18%) had severe/complicated malaria and 28 (4.6%) died. HIV-infected patients were more likely to vomit or be confused and were more likely to be admitted to hospital (P = 0.05). In patients admitted to hospital, HIV infection was associated with severe/complicated malaria [adjusted odds ratio (OR) 2.3; 95% confidence interval (CI), 1.4-3.9] and with death (OR 7.5; 95% CI, 2.2-25.1). Acidosis and coma were also strong independent risk factors for death. CONCLUSION: HIV infection had an unexpectedly large association with the outcome of falciparum malaria in a region of unstable transmission. Both diseases are widespread in Africa and these results add to the body of knowledge suggesting an interaction of significant public health importance between HIV and malaria in Africa.

Childhood malaria in a region of unstable transmission and high human immunodeficiency virus prevalence.

BACKGROUND: Malaria and HIV are important pediatric problems in sub-Saharan Africa. It is uncertain how HIV-related immunosuppression and malaria interact in children. We aimed to describe associations among HIV status, presentation and outcome from malaria in children from Hlabisa district, KwaZulu-Natal, South Africa, a region of high HIV prevalence and unstable Plasmodium falciparum transmission. METHODS: Consecutive febrile children were screened for malaria with a rapid antigen test. After consent was given, clinical data were recorded, and blood spots were obtained for HIV antibody testing. Cases were managed according to national guidelines. RESULTS: Malaria was diagnosed in 663 children, of whom 10.1% were HIV antibody-positive. Semiquantitative asexual and sexual stage parasitemia densities were unrelated to HIV status. Overall 161 children were hospitalized; 19 (12%) were <1 year old; and 41 (25%) had severe/complicated malaria. Severe disease presented more frequently in HIV antibody-positive than in HIV-uninfected children (P = 0.05), particularly in those >1 year old with coma (P = 0.02) and hypoglycemia (P = 0.05). Receiving parenteral antibiotics was associated with severe disease (odds ratio, 3.0; 95% confidence interval, 1.3 to 6.7) whereas a low white blood cell count (<4 x 10(6)/l) was associated with nonsevere disease (odds ratio, 0.4; 95% confidence interval, 0.2 to 0.8). Seven children (4.3%) died. Coma, age <1 year and low white blood cell count were the clearest predictors of poor outcome. CONCLUSION: HIV infection was associated with severe/complicated malaria, although the magnitude of the effect may be relatively small. Given that both malaria and HIV are widespread in Africa, even small effects may generate significant morbidity and mortality and major public health consequences.