Infection after intramedullary nailing of femoral and tibial diaphyseal fractures.

PURPOSE: Management of fracture-related infection (FRI) after intramedullary fixation (IF) is a challenge. The aim of the present study is to describe a series of 26 patients with FRI after IF and to evaluate factors possibly related to the outcome. METHODS: Baseline variables were obtained at the time of IF: age, sex, body mass index, affected bone, open fracture, substance abuse, use of an external fixator, type of nail, reaming, soft-tissue reconstruction and surveillance culture result. After diagnosis of the infection, information was obtained about the time interval between IF and diagnosis and classification according to both the Willeneger and Roth and Makridis systems. Treatment modalities were grouped and analysed according to: use of antimicrobials, surgical debridement, nail removal or retention and spacer use. Cultures of bone or deep soft tissues were performed. Patients were followed up for 12 months, and outcomes (remission, relapse, death and loss of follow-up) were evaluated, as well as fracture consolidation. RESULTS: Remission was observed in 42.3% of patients. There was no significant association between any baseline variable and outcome. There was a significant association between Makridis stage 2 classification and recurrence or death. Treatment strategy was not significantly associated with outcome, and 65.4% of cases had positive culture results, with Enterobacter cloacae as the predominant agent. Consolidation was observed in 81.8% of patients and was not significantly related to the outcome. CONCLUSION: There was a significant association between Makridis classification and the outcome. Consolidation rate was not associated with the outcome regarding the treatment of the infection.

Experience with SARS-CoV-2 in an orthopaedic hospital.

Background: Concerns about nosocomial transmission of SARS-CoV-2 have been described since the COVID-19 pandemic was first reported and cases of hospital-acquired (HA) COVID-19 and COVID-19 outbreaks have been reported even in clinical areas not intended for the specific care of COVID-19 and declared as "non-COVID" areas. Methods: Retrospective analysis of measures to prevent of hospital acquisition of COVID-19 in patients admitted to a tertiary referral specialist orthopaedic hospital in Brazil in which emergency care was maintained during the pandemic. Results: The proportion of HA-COVID-19 (0.07%) was lower than the value reported for general healthcare in Brazil (0.72%, P<0.001). The integration of several clinical teams to maintain a constant surveillance system, as well as the immediate isolation of patients with any compatible symptoms of COVID-19 and the restriction from work and the testing of symptomatic healthcare workers, were an important part of the strategies adopted. Conclusion: We suggest that the described strategies for preventing the nosocomial spread of SARS-CoV-2 contributed to the observed proportion of HA-COVID-19 to be significantly lower than the reported national value. Future studies that investigate these and other preventative measures are important so that hospitals are prepared for further periods of a high incidence of COVID-19, as well as for other epidemics associated with respiratory transmission.

Tigecycline Versus Colistin in the Treatment of Carbapenem-resistant Acinetobacter baumannii Complex Osteomyelitis.

Background: Acinetobacter baumannii complex is an increasingly important cause of osteomyelitis. It is considered a difficult to treat agent, due to increasing antimicrobial resistance and few available therapeutic options. Objective: To compare effectiveness and tolerability of tigecycline and colistin in patients with osteomyelitis caused by carbapenem-resistant A. baumannii complex (CRABC). Methods: This retrospective review included all patients admitted to a 150-bed tertiary hospital from 2007 to 2015 with microbiologically confirmed CRABC osteomyelitis for which they received tigecycline or colistin. Data on demographic and clinical characteristics, adverse events, and outcomes 12 months after the end of antimicrobial treatment were analysed and stratified according to the antimicrobial used. Results: 65 patients were included, 34 treated with colistin and 31 with tigecycline. There were significantly more men (P = 0.028) in the colistin group, and more smokers (P = 0.021) and greater occurrence of chronic osteomyelitis (P = 0.036) in the tigecycline treatment group. Median duration of therapy was 42.5 days for colistin and 42 days for tigecycline, with no significant difference. Overall incidence of adverse events was higher in the colistin group (P = 0.047). In particular, incidence of renal impairment was also higher in this group (P = 0.003). Nausea and vomiting were more frequent with tigecycline (P = 0.046). There were no significant differences between groups in relapse, amputation, or death. Conclusions: Tigecycline had a better safety profile than colistin in the treatment of osteomyelitis due to CRABC, with no significant difference in outcomes after 12 months of follow-up.

Incidence and risk factors associated with infection after intramedullary nailing of femoral and tibial diaphyseal fractures: Prospective study.

BACKGROUND: Diaphyseal fractures of femur and tibia are prominent due to its high incidence and high economic and social impact. Intramedullary nailing (IN) is the surgical procedure of choice. Surgical site infection (SSI) related to this procedure is considered a difficult to treat complication. AIMS: Determine the incidence of SSI after IN of femoral and tibial diaphyseal fractures and evaluate possible risk factors. METHODS: Prospective observational cohort study. SSI was defined according to CDC-NHSN criteria and surveillance period for the occurrence of infection was 12 months. Incidence of SSI was calculated as the ratio between the number of patients with SSI and total number of patients. Analysis of potential risk factors included patients-related factors (age, gender, body mass index, active foci of infection, immunosuppressive conditions, ASA score, alcohol or illicit drug abuse, smoking, polytrauma, etiology of fracture, type of fracture if closed or open, classification of fracture according to Müller AO, Tcherne classification for closed fractures, Gustilo-Anderson classification for open fractures, previous surgical manipulation, use of blood products); environmental and surgical-related factors (surgical wound classification, duration of surgery, hair removal, intraoperative contamination, antimicrobial use, presence of drains, hypothermia or hypoxia in the perioperative period, type of IN used, reaming, need for soft tissue reconstruction, use of negative pressure therapy) and microbiota-related factors (cultures of nasopharyngeal swabs forStaphylococcus aureus and axillary/inguinal/perineal swab for Acinetobacter baumannii). RESULTS: 221 patients were included and completed the 12-month follow-up period. Incidence of SSI was 11.8%. In the initial analysis by unadjusted logistic regression, following factors were associated SSI: Müller AO classification of the fracture morphology groups 2 or 3, previous use of external fixator, presence of drains, use of negative pressure therapy and need for muscle or skin flap repair. In the multiple logistic regression-adjusted analysis, previous use of external fixator and need for muscle or skin flap repair remained associated with SSI. CONCLUSIONS: Incidence of SSI associated with IN for femoral and tibial diaphyseal fractures was 11.8%. Previous use of external fixators and need for muscle or skin flap repair were factors associated with occurrence of infection.

Recommendations for outpatient parenteral antimicrobial therapy in Brazil

ABSTRACT A panel of national experts was convened by the Brazilian Infectious Diseases Society in order to determine the recommendations for outpatient parenteral antimicrobial therapy (OPAT) in Brazil. The following aspects are covered in the document: organization of OPAT programs; patient evaluation and eligibility criteria, including clinical and sociocultural factors; diagnosis of eligibility; venous access and antimicrobial infusion devices; protocols for antimicrobial use and monitoring and cost-effectiveness.

Recommendations for outpatient parenteral antimicrobial therapy in Brazil.

A panel of national experts was convened by the Brazilian Infectious Diseases Society in order to determine the recommendations for outpatient parenteral antimicrobial therapy (OPAT) in Brazil. The following aspects are covered in the document: organization of OPAT programs; patient evaluation and eligibility criteria, including clinical and sociocultural factors; diagnosis of eligibility; venous access and antimicrobial infusion devices; protocols for antimicrobial use and monitoring and cost-effectiveness.

Recommendations for the treatment of osteomyelitis

With the advances in surgical treatment, antibiotic therapy and the current resources for accurate diagnosis and differentiated approaches to each type of osteomyelitis, better results are being obtained in the treatment of this disease. After a careful literature review carried out by a multiprofessional team, some conclusions were made in order to guide medical approach to different types of osteomyelitis, aiming to obtain better clinical outcomes and reducing the social costs of this disease. Acute and chronic osteomyelitis are discussed, with presentation of the general epidemiological concepts and the commonly used classification systems. The main guidelines for the clinical, laboratory and imaging diagnosis of infections are discussed, as well as the guidelines for surgical and antimicrobial treatments, and the role of hyperbaric oxygen as adjuvant therapy.

Recommendations for the treatment of osteomyelitis.

With the advances in surgical treatment, antibiotic therapy and the current resources for accurate diagnosis and differentiated approaches to each type of osteomyelitis, better results are being obtained in the treatment of this disease. After a careful literature review carried out by a multiprofessional team, some conclusions were made in order to guide medical approach to different types of osteomyelitis, aiming to obtain better clinical outcomes and reducing the social costs of this disease. Acute and chronic osteomyelitis are discussed, with presentation of the general epidemiological concepts and the commonly used classification systems. The main guidelines for the clinical, laboratory and imaging diagnosis of infections are discussed, as well as the guidelines for surgical and antimicrobial treatments, and the role of hyperbaric oxygen as adjuvant therapy.

Periprosthetic joint infections.

Implantation of joint prostheses is becoming increasingly common, especially for the hip and knee. Infection is considered to be the most devastating of prosthesis-related complications, leading to prolonged hospitalization, repeated surgical intervention, and even definitive loss of the implant. The main risk factors to periprosthetic joint infections (PJIs) are advanced age, malnutrition, obesity, diabetes mellitus, HIV infection at an advanced stage, presence of distant infectious foci, and antecedents of arthroscopy or infection in previous arthroplasty. Joint prostheses can become infected through three different routes: direct implantation, hematogenic infection, and reactivation of latent infection. Gram-positive bacteria predominate in cases of PJI, mainly Staphylococcus aureus and Staphylococcus epidermidis. PJIs present characteristic signs that can be divided into acute and chronic manifestations. The main imaging method used in diagnosing joint prosthesis infections is X-ray. Computed tomography (CT) scan may assist in distinguishing between septic and aseptic loosening. Three-phase bone scintigraphy using technetium has high sensitivity, but low specificity. Positron emission tomography using fluorodeoxyglucose (FDG-PET) presents very divergent results in the literature. Definitive diagnosis of infection should be made by isolating the microorganism through cultures on material obtained from joint fluid puncturing, surgical wound secretions, surgical debridement procedures, or sonication fluid. Success in treating PJI depends on extensive surgical debridement and adequate and effective antibiotic therapy. Treatment in two stages using a spacer is recommended for most chronic infections in arthroplasty cases. Treatment in a single procedure is appropriate in carefully selected cases.

Impact of restriction of cefepime use on the antimicrobial susceptibility of Gram-negative bacilli related to healthcare-associated infections in an orthopedic hospital.

INTRODUCTION: In recent decades, antimicrobial resistance has become a public health problem, particularly in cases of healthcare-associated infections. Interaction between antibiotic consumption and resistance development is of particular interest regarding Gram-negative bacilli, whose growing resistance has represented a great challenge. OBJECTIVE: Assess the impact of restriction of cefepime use on antimicrobial susceptibility among the Gram-negative bacilli (GNB) most frequently involved in healthcare-associated infections (HAI). METHODS: DATA RELATING TO HOSPITAL OCCUPANCY AND MORTALITY RATES, INCIDENCE OF HAI, INCIDENCE OF GNB AS CAUSATIVE AGENTS OF HAI, ANTIMICROBIAL CONSUMPTION AT THE HOSPITAL AND ANTIMICROBIAL SUSCEPTIBILITY OF GNB RELATED TO HAI WERE COMPARED BETWEEN TWO PERIODS: a 24-month period preceding restriction of cefepime use and a 24-month period subsequent to this restriction. RESULTS: There was a significant drop in cefepime consumption after its restriction. Susceptibility of Acinetobacter baumanii improved relating to gentamicin, but it worsened in relation to imipenem, subsequent to this restriction. For Pseudomonas aeruginosa, there was no change in antimicrobial susceptibility. For Klebsiella pneumoniae and Enterobacter spp, there were improvements in susceptibility relating to ciprofloxacin. CONCLUSION: Restriction of cefepime use had a positive impact on K. pneumoniae and Enterobacter spp, given that after this restriction, their susceptibilities to ciprofloxacin improved. However, for A. baumanii, the impact was negative, given the worsening of susceptibility to imipenem.

Economic impact of treatment for surgical site infections in cases of total knee arthroplasty in a tertiary public hospital in Brazil.

The aim of this study was to estimate the additional cost of treatment of a group of nosocomial infections in a tertiary public hospital. A retrospective observational cohort study was conducted by means of analyzing the medical records of 34 patients with infection after total knee arthroplasty, diagnosed in 2006 and 2007, who met the criteria for nosocomial infection according to the Centers for Disease Control and Prevention. To estimate the direct costs of treatment for these patients, the following data were gathered: length of hospital stay, laboratory tests, imaging examinations, and surgical procedures performed. Their costs were estimated from the minimum values according to the Brazilian Medical Association. The estimated cost of the antibiotics used was also obtained. The total length of stay in the ward was 976 days, at a cost of US$ 18,994.63, and, in the intensive care unit, it was 34 days at a cost of US$ 5,031.37. Forty-two debridement procedures were performed, at a cost of US$ 5,798.06, and 1965 tests (laboratory and imaging) were also performed, at a cost of US$ 15,359.25. US$ 20,845.01 was spent on antibiotics and US$ 1,735.16 on vacuum assisted closure therapy, microsurgical flaps, implant removal, spacer use, and surgical revision. The total additional cost of these cases of hospital infection in 2006 and 2007 was of US$ 91,843.75. Based on that, we demonstrate that the high cost of treatment for hospital infections emphasizes the importance of taking measures to prevent and control hospital infection.

The impact of ertapenem use on the susceptibility of Pseudomonas aeruginosa to imipenem: a hospital case study.

We sought to evaluate the indirect impact of ertapenem use for the treatment of extended-spectrum beta-lactamase-producing Enterobacteriaceae infections in our hospital on the susceptibility of Pseudomonas aeruginosa to imipenem. The use of ertapenem was mandated for treatment of extended-spectrum beta-lactamase-producing Enterobacteriaceae infections in the absence of nonfermenting gram-negative bacilli for 1 year. The use of imipenem was restricted. Imipenem consumption decreased 64.5%. Ertapenem consumption was 42.57 defined daily doses per 1,000 patient-days. None of the 18 P. aeruginosa isolates recovered after ertapenem introduction were imipenem-resistant, compared with 4 of the 20 P. aeruginosa isolates recovered in the previous year.