RESUMEN
Prosthetic joint infections (PJIs) following total joint arthroplasty are a significant and costly complication. To address fragmented care typically seen with separate management, we established a combined infectious disease and orthopaedic surgery clinic at Duke Health in July 2020. This clinic focuses on patients experiencing acute deterioration or multiple PJI episodes, often at the stage where amputation is the only option offered. From July 2021 to March 2024, the clinic completed 974 visits with 319 unique patients. The clinic maintained a low no-show rate of 5.0%. Treatment plans included procedures such as debridement, antibiotics and implant retention (38%), as well as implant explantation and one-stage exchange (32% each), with amputation required in only 4% of cases. The integrated clinic model facilitated real-time, multidisciplinary care, improving patient outcomes and operational efficiency. This approach offers a promising model for managing complex infections.
Asunto(s)
Infecciones Relacionadas con Prótesis , Humanos , Infecciones Relacionadas con Prótesis/terapia , Femenino , Masculino , Anciano , Persona de Mediana Edad , Desbridamiento/métodos , Desbridamiento/estadística & datos numéricos , Antibacterianos/uso terapéutico , Procedimientos Ortopédicos/efectos adversos , Procedimientos Ortopédicos/métodos , Procedimientos Ortopédicos/estadística & datos numéricos , Enfermedades Transmisibles/terapiaRESUMEN
¼: As total joint arthroplasty volume continues to grow nationwide, more uncommon complications such as metal implant hypersensitivity are reported with greater frequency in the literature. ¼: Metal hypersensitivity is a challenging diagnosis given the potentially vague symptomology. It should be considered a diagnosis of exclusion, necessitating careful consideration of other potential etiologies of a failing implant before arriving at the final diagnosis of metal hypersensitivity. ¼: Patients can experience substantial morbidity from implant rejection and in severe, refractory cases may even require revision arthroplasty and conversion to a hypoallergenic implant. ¼: Given the complex nature of the condition, successful treatment of metal hypersensitivity to orthopaedic implants is best achieved through the use of a multidisciplinary, team-based approach. Immunologists, radiologists, and infectious disease physicians as well as orthopaedic surgeons and mechanical engineers are all vital in appropriate diagnosis and treatment of the condition.
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Cirujanos Ortopédicos , Ortopedia , Humanos , ArtroplastiaRESUMEN
BACKGROUND: There is contradicting evidence on the diagnostic value of inflammatory biomarkers for periprosthetic joint infection (PJI). We sought to quantify the sensitivity of D-dimer for acute and chronic PJI diagnosis and evaluate D-dimer lab values in the 90-day postoperative window in a control cohort of primary joint arthroplasty patients for comparison. METHODS: An institutional database was queried for patients undergoing revision procedures for PJI after total hip arthroplasty (THA) and total knee arthroplasty (TKA) from 2014 to present. CRP, ESR, and D-dimer were collected within 90 days pre and postoperatively and sensitivities for the diagnosis of PJI were calculated. The control group included patients who underwent a negative diagnostic workup for deep venous thrombosis (DVT) or pulmonary embolus (PE) and had a D-dimer lab collected within 90 days postoperatively from primary total joint arthroplasty (TJA). RESULTS: A total of 604 PJI patients were identified, and 81 patients had D-dimer, ESR, and CRP collected. There were 50/81 acute PJI patients and 31/81 chronic PJI patients who had median D-dimer values of 2,136.5 ng/mL [interquartile range (IQR): 1,642-3,966.5] and 3,336 ng/mL [IQR: 1,976-5,594]. Only the chronic PJI group had significantly higher D-dimer values when compared to the control cohort (P = .009). The sensitivity of D-dimer was calculated to be 92% and 93.5% in the acute and chronic PJI groups, respectively. CONCLUSION: Serum D-dimer may not have high diagnostic utility for acute PJI, especially in the setting of recent surgery; however, it still may be useful for patients who have chronic PJI.
Asunto(s)
Artritis Infecciosa , Artroplastia de Reemplazo de Cadera , Infecciones Relacionadas con Prótesis , Humanos , Proteína C-Reactiva/análisis , Sedimentación Sanguínea , Infecciones Relacionadas con Prótesis/cirugía , Productos de Degradación de Fibrina-Fibrinógeno , Biomarcadores , Artroplastia de Reemplazo de Cadera/efectos adversos , Artritis Infecciosa/cirugía , Sensibilidad y Especificidad , Estudios RetrospectivosRESUMEN
BACKGROUND: Coagulase-negative staphylococci (CoNS) are biofilm-producing pathogens whose role in periprosthetic joint infection (PJI) is increasing. There is little data on the prognosis and treatment considerations in the setting of PJI. We sought to evaluate the clinical characteristics, outcomes, and complications in these patients. METHODS: This is a retrospective cohort study of adult patients at a single tertiary medical center from 2009 to 2020 with culture-proven CoNS PJI after total knee arthroplasty, as diagnosed by Musculoskeletal Infection Society criteria. The primary outcome was treatment success, with failure defined as recurrent CoNS PJI, recurrent PJI with a new pathogen, and/or chronic oral antibiotic suppression at one year postoperatively. RESULTS: We identified 55 patients with a CoNS total knee arthroplasty PJI with a mean follow-up of 29.8 months (SD: 16.3 months). The most commonly isolated organism was Staphylococcus epidermidis (n = 36, 65.5%). The overall prevalence of methicillin resistance was 63%. Surgical treatment included surgical debridement, antibiotics, and implant retention in 25 (45.5%) cases and two-stage revision (22 articulating and eight static antibiotic-impregnated spacers). At one-year follow-up, only 47% of patients had successful management of their infection. The surgical debridement, antibiotics, and implant retention cohort had the higher rate of treatment failure (60.0%) compared to two-stage revision (46.7%). CONCLUSION: These results indicate a poor rate of success in treating CoNS PJI. This likely represents the interplay of inherent virulence through biofilm formation and decreased antibiotic efficacy.
Asunto(s)
Artritis Infecciosa , Infecciones Relacionadas con Prótesis , Adulto , Antibacterianos/uso terapéutico , Artritis Infecciosa/etiología , Coagulasa/uso terapéutico , Desbridamiento/métodos , Humanos , Infecciones Relacionadas con Prótesis/epidemiología , Infecciones Relacionadas con Prótesis/etiología , Infecciones Relacionadas con Prótesis/terapia , Estudios Retrospectivos , Staphylococcus , Resultado del TratamientoRESUMEN
OBJECTIVE: To examine the infectious features of patients with urinary pubic symphysis fistula (UPF) and their association with osteomyelitis. METHODS: We conducted a review of our quality improvement database for 36 patients with UPF undergoing bone resection and extirpative surgery from October 2012 to January 2019. An assessment of bone and urine cultures was carried out along with surgical, radiologic, and demographic data. We analyzed descriptive statistics and used Fisher Exact Tests and unpaired Welch t tests to assess for associations with positive bone cultures. RESULTS: In our cohort, 33 patients (91.7%) had positive bone cultures with the 3 most common organisms being candida (22.0%), enterococcus (18.0%), and pseudomonas (10.0%). There was a correlation between positive preoperative urine culture and positive bone culture (P <.01), with 63.0% of those with positive urine cultures growing the same organism on bone culture. CONCLUSION: In this series, 91.7% of patients undergoing extirpative surgery for UPF at our institution have positive bone cultures at time of pubic bone debridement. Additionally, we demonstrate a statistically significant correlation between positive urine cultures and positive bone cultures in these patients. This supports the need for a multidisciplinary approach including infectious disease, orthopedic surgery and reconstructive urology in order to address this complex clinical condition.
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Enfermedades Óseas/microbiología , Fístula/microbiología , Osteomielitis/microbiología , Neoplasias de la Próstata , Hueso Púbico , Sínfisis Pubiana , Fístula Urinaria/microbiología , Anciano , Anciano de 80 o más Años , Supervivientes de Cáncer , Humanos , Masculino , Persona de Mediana Edad , Osteomielitis/cirugía , Estudios RetrospectivosAsunto(s)
Pólipos del Colon/parasitología , Esquistosomiasis Japónica/diagnóstico , Esquistosomiasis Japónica/patología , Antihelmínticos/administración & dosificación , Antihelmínticos/uso terapéutico , Pólipos del Colon/patología , Pólipos del Colon/cirugía , Relación Dosis-Respuesta a Droga , Heces/parasitología , Humanos , Masculino , Persona de Mediana Edad , Praziquantel/administración & dosificación , Praziquantel/uso terapéutico , Esquistosomiasis Japónica/tratamiento farmacológico , Esquistosomiasis Japónica/cirugíaRESUMEN
A 45-year-old male with a prosthetic aortic valve presented to the hospital with several months of generalized malaise. On admission, he was noted to have anemia of unclear etiology and subsequently became febrile with multiple blood cultures growing Lactococcus garvieae. Inpatient workup was concerning for infectious endocarditis (IE) secondary to Lactococcus. The patient was discharged home with appropriate antimicrobial therapy; however, he was readmitted for persistent, symptomatic anemia and underwent colonoscopy, which revealed innumerable colonic polyps consistent with Familial Adenomatous Polyposis (FAP) that was later confirmed with genetic testing. Surveillance computed tomography (CT) imaging of the aortic repair later demonstrated valve dehiscence with surrounding fluid collection; he underwent redo surgery and was found to have destruction of the aortic annulus and a large pseudoaneurysm. Histopathology of the valve prosthesis confirmed IE. It is suspected that the patient developed Lactococcus IE from enteric translocation. Review of the literature provides several reports of Lactococcus infections in association with underlying gastrointestinal disease, including colorectal cancer. Given this association, we raise the question of whether the diagnosis of Lactococcus IE should evoke suspicion and encourage evaluation for gastrointestinal pathology, as occurs with Streptococcus bovis.
RESUMEN
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.
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Osteomielitis/diagnóstico , Osteomielitis/terapia , Espondilitis/diagnóstico , Espondilitis/terapia , Adulto , Antibacterianos/uso terapéutico , Desbridamiento , HumanosRESUMEN
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.
Asunto(s)
Osteomielitis/diagnóstico , Osteomielitis/terapia , Espondilitis/diagnóstico , Espondilitis/terapia , Adulto , Antibacterianos/uso terapéutico , Desbridamiento , Humanos , Guías de Práctica Clínica como Asunto , SociedadesRESUMEN
OBJECTIVE: To describe pelvic bone osteomyelitis in the prostate cancer survivor, to report on clinical presentation and treatment, and to suggest an algorithmic approach to managing this syndrome complex. MATERIALS AND METHODS: A retrospective chart review from January 2011 to June 2014 was performed to identify prostate cancer patients with pubic symphysis osteomyelitis at a tertiary-care academic medical center with emphasis on genitourinary cancer survivorship. Data on clinical presentation and outcomes were reviewed. RESULTS: Ten patients were diagnosed with having osteomyelitis of the pubic symphysis with or without extension into the pubic rami. Three patients had associated rectal fistulas. Four patients had radical prostatectomy, 5 patients received radiotherapy, and 1 patient received high-intensity focused ultrasound as the primary treatment for prostate cancer. The most common presenting symptoms were pelvic and suprapubic pain, difficulty in walking, and recurrent urinary infections at a median of 7 years after prostate cancer treatment (range, 1.5-16 years). Eight of the 10 patients underwent pubic bone debridement with urinary and fecal diversion when needed. Two patients continue to be managed conservatively with suppressive antibiotics owing to low disease burden. Complete resolution of symptoms was noted in patients undergoing operative intervention, without any pelvic ring instability due to pubic bone resection. CONCLUSION: The combination of pelvic pain, difficulty with ambulation, and recurrent infections in a prostate cancer survivor should prompt investigation for pubic bone osteomyelitis-a poorly recognized syndrome complex that is best managed in a multidisciplinary setting.
Asunto(s)
Osteomielitis/diagnóstico , Osteomielitis/terapia , Neoplasias de la Próstata/complicaciones , Sínfisis Pubiana , Algoritmos , Humanos , Masculino , Osteomielitis/etiología , Estudios Retrospectivos , SobrevivientesRESUMEN
OBJECTIVES: Describe two 2009-H1N1 influenza outbreaks in university-based summer camps and the implementation of an infection control program. PARTICIPANTS: 7,906 campers across 73 residential camps from May 21-August 2, 2009. METHODS: Influenza-like-illness (ILI) was defined as fever with cough and/or sore throat. Influenza A was identified using PCR or rapid-antigen testing. We implemented an infection control program consisting of education, hand hygiene, disinfection, symptom screening, and ILI case management. RESULTS: An initial ILI cluster involved 60 cases across 3 camps from June 17-July 2. Academic Camp-1 had the most cases (n = 45, 14.9% attack rate); influenza A was identified in 84% of those tested. Despite implementation of an infection control program, a second ILI cluster began on July 12 in Academic Camp-2 (n = 47, 15.0% attack rate). CONCLUSIONS: ILI can spread rapidly in a university-based residential camp. Infection control is an important aspect of the medical response but is challenging to implement.
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Brotes de Enfermedades/prevención & control , Control de Infecciones/métodos , Subtipo H1N1 del Virus de la Influenza A , Gripe Humana/prevención & control , Adolescente , Antivirales/uso terapéutico , Acampada , Quimioprevención/métodos , Humanos , Gripe Humana/diagnóstico , Gripe Humana/epidemiología , Tamizaje Masivo/métodos , North Carolina , Oseltamivir/uso terapéutico , Estudiantes/estadística & datos numéricos , Universidades , Adulto JovenRESUMEN
BACKGROUND: Little is known about the clinical presentation and course of novel H1N1 influenza in summer camps. OBJECTIVES: To describe the clinical course and evaluate the effect of influenza treatment in a summer camp population. STUDY DESIGN: Two large influenza outbreaks occurred in university-based residential camps between May 21 and August 2, 2009. Through active daily surveillance, medical evaluation at symptom onset, and data collection during isolation, we describe the clinical course of a large outbreak of novel H1N1 influenza. RESULTS: Influenza-like illness (ILI) was documented in 119 individuals. Influenza A was confirmed in 66 (79%) of 84 samples tested. Three early samples were identified as novel H1N1. ILI cases had an average age of 15.7 years and 52% were male. Sixty-three were treated with oseltamivir or zanamivir, which was initiated within 24h of diagnosis. Cough, myalgia and sore throat occurred in 69, 64 and 63% of cases, respectively. The highest temperature over the course of illness (T(max)) occurred within 48h after symptom onset in 87.5% of individuals. Average T(max) was 38.4 degrees C (range 36.1-40.2 degrees C). Among confirmed influenza cases, 69% defervesced by 72h and 95% defervesced by 96h. Defervescence at 72h was not different in the treated and untreated groups (p=0.12). CONCLUSIONS: Novel H1N1 generally has a mild, self-limited course in healthy adolescent campers. Defervescence occurred within 72h and was unaffected by treatment.
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Brotes de Enfermedades , Subtipo H1N1 del Virus de la Influenza A/aislamiento & purificación , Gripe Humana/tratamiento farmacológico , Gripe Humana/patología , Adolescente , Antivirales/uso terapéutico , Femenino , Humanos , Gripe Humana/epidemiología , Gripe Humana/virología , Masculino , Oseltamivir/uso terapéutico , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiología , Zanamivir/uso terapéuticoRESUMEN
Physicians caring for febrile returned travelers face the difficult task of recognizing the typical and atypical features of more than 16 known rickettsial diseases and separating these diseases from potentially serious nonrickettsial diseases. Currently available diagnostic tools are inadequate for timely diagnosis. This review summarizes the English-language literature concerning imported rickettsial diseases in international travelers and describes important clinical principles in diagnosis and treatment of these illnesses. -Travelers with imported rickettsial disease often become sick before or within a few days of return from an endemic region. Illness that begins more than 18 days after return is unlikely to be rickettsial in origin. The absence of a skin rash or exposure to a vector should not dissuade clinicians from considering the possibility of a rickettsial disease in a returned traveler. Finally, if empiric therapy does not result in defervescence within 48 hours, an alternative nonrickettsial illness should be strongly considered.