Early Switch From Intravenous to Oral Antibiotics in Skin and Soft Tissue Infections: An Algorithm-Based Prospective Multicenter Pilot Trial.

Background: In hospitalized patients with skin and soft tissue infections (SSTIs), intravenous (IV) empiric antibiotic treatment is initiated. The best time point for switching from IV to oral treatment is unknown. We used an algorithm-based decision tree for the switch from IV to oral antibiotics within 48 hours and aimed to investigate the treatment outcome of this concept. Methods: In a nonrandomized trial, we prospectively enrolled 128 patients hospitalized with SSTI from July 2019 to May 2021 at 3 institutions. Clinical and biochemical response data during the first week and at follow-up after 30 days were analyzed. Patients fulfilling criteria for the switch from IV to oral antibiotics were assigned to the intervention group. The primary outcome was a composite definition consisting of the proportion of patients with clinical failure or death of any cause. Results: Ninety-seven (75.8%) patients were assigned to the intervention group. All of them showed signs of clinical improvement (ie, absence of fever or reduction of pain) within 48 hours of IV treatment, irrespective of erythema finding or biochemical response. The median total antibiotic treatment duration was 11 (interquartile range [IQR], 9-13) days in the invention group and 15 (IQR, 11-24) days in the nonintervention group (P < .001). The median duration of hospitalization was 5 (IQR, 4-6) days in the intervention group and 8 (IQR, 6-12) days in the nonintervention group (P < .001). There were 5 (5.2%) failures in the intervention group and 1 (3.2%) in the nonintervention group after a median follow-up of 37 days. Conclusions: In this pilot trial, the proposed decision algorithm for early switch from IV to oral antibiotics for SSTI treatment was successful in 95% of cases. Clinical Trials Registration. ISRCTN15245496.

One-stage revision of infected hip arthroplasty: outcome of 39 consecutive hips.

PURPOSE: There are various options for treating periprosthetic joint infection (PJI). Two-stage exchange has traditionally been the gold standard. However, if the appropriate surgical intervention is chosen according to a rational algorithm, the outcome is similar when using all types of interventions. In an observational cohort study, the outcome of patients with PJI after hip replacement treated with one-stage revision was analysed. METHODS: All patients fulfilling all criteria for one-stage exchange according to the Infectious Diseases Society of America (IDSA) guidelines and six without preoperative identification of a microorganism were included. Implant removal, debridement and cemented or uncemented reimplantations were performed in a single intervention. If a cemented device was implanted, commercially available gentamicin cement was used in all cases. Antibiotic treatment was administered intravenously for at least 2 weeks, followed by oral therapy for a total duration of 3 months. Patients had standardised clinical and radiological follow-up visits. RESULTS: Between 1996 and 2011, 38 patients (39 hips) were treated with a one-stage procedure and followed for at least 2 years. Coagulase-negative staphylococci were the most frequent pathogens, and polymicrobial infection was observed in five cases. In 25 hips, an uncemented revision stem was implanted, and 37 hips received an acetabular reinforcement ring. The mean follow-up was 6.6 (2.0-15.1) years. No patient had persistent, recurrent or new infection. There were four stem revisions for aseptic loosening. The mean Harris Hip Score was 81 points (26-99) at the final follow-up. CONCLUSIONS: Excellent cure rate and function seen in our study suggest that one-stage exchange is a safe procedure, even without local antibiotic treatment, provided that the patient has no sinus tract or severe soft tissue damage, no major bone grafting is required and the microorganism is susceptible to orally administered agents with high bioavailability.

Delayed diagnosis of cryptococcal meningoencephalitis due to negative cryptococcal antigen test.

Cryptococcus spp. commonly causes infection in immunocompromised hosts. Clinical presentation of cryptococcal meningoencephalitis (CM) is variable, but headache, fever and a high intracranial pressure should suggest the diagnosis. The cryptococcal antigen test is a specific and sensitive rapid test that can be performed on blood or cerebrospinal fluid. We report a case of CM in a patient with previously undetected lymphocytopenia. Because cryptococcal antigen test results were negative, diagnosis and treatment were delayed.

Risk factors for periprosthetic ankle joint infection: a case-control study.

BACKGROUND: Periprosthetic ankle joint infection is a feared complication of total ankle arthroplasty because the implant fails in the majority of cases. However, risk factors for developing these infections are unknown. METHODS: We aimed to determine risk factors for infection in a matched case-control study that included twenty-six patients with periprosthetic ankle joint infection and two control groups, each consisting of fifty-two patients. RESULTS: The prevalence of periprosthetic ankle joint infection within our cohort was 4.7%. Four infections (15%) had a hematogenous origin and twenty-two (85%), an exogenous origin. Staphylococcus aureus was the most common pathogen, followed by coagulase-negative staphylococci. Preoperative predisposing factors associated with infection included prior surgery at the site of infection (odds ratio [OR] = 4.56, 95% confidence interval [CI] = 0.98 to 21.35, and OR = 4.78, 95% CI = 1.53 to 14.91, in comparison with the two control groups) and a low American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score (35.8 versus 49.8 and 47.6 in the two control groups, p ≤ 0.02). The mean duration of the index surgery was significantly longer in the case group than in both control groups (119 versus eighty-four and ninety-three minutes, p ≤ 0.02). After surgery, persistent wound dehiscence (OR = 15.38, 95% CI = 2.91 to 81.34, p = 0.01, in comparison with both control groups) and secondary wound drainage (OR = 7.00, 95% CI = 1.45 to 33.70, and OR = 5.31, 95% CI = 1.01 to 26.78, in comparison with the two control groups, p ≤ 0.04) were associated with the development of a periprosthetic ankle joint infection. CONCLUSIONS: Patients at risk for periprosthetic ankle joint infection following total ankle arthroplasty include those with a history of surgery on the ankle, a low preoperative AOFAS hindfoot score, and a long operative time. Postoperatively, patients with a prolonged wound dehiscence or a secondary wound-healing problem are also at risk for infection.

Dentoalveolar injury related to general anaesthesia: a 14 years review and a statement from the surgical point of view based on a retrospective analysis of the documentation of a university hospital.

INTRODUCTION: Damage to dentoalveolar structures related to general anaesthesia is a well-known complication and may represent a relevant morbidity for affected patients. Central documentation of perioperative dentoalveolar injuries was performed since 1990 in the Department of Anaesthesiology and Intensive Care Medicine in cooperation with the Department of Oral and Maxillofacial Surgery at the Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum. Documentation of perioperative dentoalveolar injury consisted of anaesthesia charts, reports of the anaesthesiologists and consultant maxillofacial surgeons. MATERIALS AND METHODS: Retrospective analysis of the data from 1990 to 2004 was performed according to this documentation with respect to incidence, matter, distribution of dental injury and therapeutic consequences. RESULTS: Within 14 years 82 'dental injuries' with 103 affected teeth were documented in calculated 375,000 general anaesthesias. Incidence of 0.02% was very constant with an average of 5.5 events/year. Eighty-nine percent of the documented injuries occurred during scheduled operative procedures. Only 32.9% of the injuries took place during endotracheal intubation. In about 50% the injury was not related to intubation or extubation but happened during general anaesthesia. In 80% the dental injury was estimated by the anaesthesiologist as 'not avoidable'. In 83% pre-existing affection or structural injury of intraoral tissues was documented, in 32.7% of the affections sufficient therapy could be provided already during inhospital stay. CONCLUSION: Perioperative dentoalveolar injury is surely an annoying complication of general anaesthesia. However incidence is rare and seems to be unavoidable. Pre-existing damage to dentoalveolar structures is the main risk for additional injuries related to general anaesthesia. Adequate therapy can be provided by interdisciplinary concepts. There should be a fair balance between the benefit of the surgical procedure and the risk of dental injury related to general anaesthesia. Awareness of the problem and proper documentation are important factors for adequate management in liability cases.