The Alpha-defensin Test for Periprosthetic Joint Infections Is Not Affected by Prior Antibiotic Administration.

Clin Orthop Relat Res. 2016 Jul;474(7):1610-5.

Shahi A1, Parvizi J1, Kazarian GS1, Higuera C2, Frangiamore S2, Bingham J3, Beauchamp C3, Valle CD4, Deirmengian C1,5.

Author information

1The Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA.

2Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA.

3Department of Orthopaedic Surgery, Mayo Clinic Phoenix, Phoenix, AZ, USA.

4Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.

5The Lankenau Institute for Medical Research, 100 Lancaster Avenue, Wynnewood, PA, 19096, USA.

Abstract

BACKGROUND:

Previous studies have demonstrated that the administration of antibiotics to patients before performing diagnostic testing for periprosthetic joint infection (PJI) can interfere with the accuracy of test results. Although a single-institution study has suggested that alpha-defensin maintains its concentration and sensitivity even after antibiotic treatment, this has not yet been demonstrated in a larger multiinstitutional study.

QUESTIONS/PURPOSES:

(1) For the evaluation of PJI, is prior antibiotic administration associated with decreased alpha-defensin levels? (2) When prior antibiotics are given, is alpha-defensin a better screening test for PJI than the traditional tests (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], fluid white blood cells, fluid polymorphonuclear cells [PMNs], and fluid culture)?

METHODS:

This retrospective study included data from 106 hip and knee arthroplasties with Musculoskeletal Infection Society-defined PJI from four centers. Of the 106 patients in this study, 30 (28%) were treated with antibiotics for PJI before diagnostic workup (ABX group), and 76 (72%) were not treated before the diagnostic workup (NO-ABX group). There were no differences in age, sex, joint, culture-negative rate, or bacteriology between groups. The patients in the ABX group had antibiotics initiated by physicians who commenced care before assessment for PJI by the treating surgeon’s service. We compared the alpha-defensin levels and sensitivity between the ABX and NO-ABX groups. Additionally, the sensitivity of the alpha-defensin test was compared to that of traditional tests for PJI among patients on antibiotics.

RESULTS:

The administration of antibiotics before performing the alpha-defensin test for PJI was not associated with a decreased median alpha-defensin level (ABX group, median 4.2 [range, 1.79-12.8 S/CO] versus NO-ABX, median 4.9 [range, 0.5-16.8 S/CO], difference of medians: 0.68 S/CO [95% confidence interval {CI}, -0.98 to 1.26], p = 0.451). Furthermore, the alpha-defensin test had a higher sensitivity (100%; 95% CI, 88.4%-100.0%) in diagnosing PJI among patients on antibiotics when compared with the ESR (69.0% [95% CI, 49.17%-84.72%], p = 0.001), the CRP (79.3% [95% CI, 60.3%-92.0%], p = 0.009), the fluid PMN% (79.3% [95% CI, 60.3%-92.0%), p = 0.009), and fluid culture (70.0% [95% CI, 50.6%-85.3%], p = 0.001).

CONCLUSIONS:

The alpha-defensin test maintains its concentration and sensitivity for PJI even in the setting of antibiotic administration. Furthermore, among patients with PJI on antibiotics, the alpha-defensin tests demonstrated a higher sensitivity in detecting PJI when compared with the ESR, CRP, fluid PMN%, and fluid culture. The high sensitivity of the alpha-defensin test, even in the setting of prior antibiotic treatment, provides excellent utility as a screening test for PJI.

LEVEL OF EVIDENCE:

Level III, diagnostic study.

PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4887359/pdf/11999_2016_Article_4726.pdf

August 26, 2016 at 3:47 pm

Staphylococcus aureus small colony variants in prosthetic joint infection.

Clinical Infectious Diseases October 15, 2006 V.43 N.8 P.961-7.

Sendi P1, Rohrbach M, Graber P, Frei R, Ochsner PE, Zimmerli W.

Author information

1Unit of Infectious Diseases, Basel University Medical Clinic Liestal, Liestal, CH-4410, Switzerland. sendi-pa@magnet.ch

Abstract

BACKGROUND:

Small colony variants of Staphylococcus aureus tend to persist despite antimicrobial therapy, especially when involved in implant-associated infections.

METHODS:

We analyzed 5 cases of hip prosthesis-associated infections due to small colony variants, including their course prior to identification of the pathogen. Biopsy investigations included microbiological examination and, in 1 case, transmission electron microscopy to detect intracellular bacteria in nonprofessional phagocytes. A treatment concept was elaborated on the basis of a published algorithm and patients were managed accordingly.

RESULTS:

The patients’ mean age was 62.2 years. All patients experienced treatment failures prior to isolation of small colony variants, despite as many as 3 surgical revisions and up to 22 months of antibiotics. Transmission electron microscopy performed on biopsy specimens from periprosthetic tissue revealed intracellular cocci in fibroblasts. All prostheses were removed without implanting a spacer, and antimicrobial agents were administered for 5.5-7 weeks. Reimplantation of the prosthesis was performed for 4 patients. Follow-ups were uneventful in all 5 cases.

CONCLUSIONS:

In the case of a poor response to adequate antimicrobial and surgical treatment in implant-associated staphylococcal infections, small colony variants should be considered and actively sought. In our case series, a 2-stage exchange without implantation of a spacer combined with antimicrobial therapy for an implant-free interval of 6-8 weeks was associated with successful outcome, with a mean follow-up of 24 months.

PDF

http://cid.oxfordjournals.org/content/43/8/961.full.pdf+html

August 26, 2016 at 8:32 am

Extended-Infusion versus standard-infusion piperacillin-tazobactam for sepsis syndromes at a tertiary medical center.

Antimicrob Agents Chemother. 2014 Aug;58(8):4470-5.

Cutro SR1, Holzman R2, Dubrovskaya Y3, Chen XJ3, Ahuja T3, Scipione MR3, Chen D2, Papadopoulos J3, Phillips MS2, Mehta SA2.

Author information

1Division of Infectious Diseases, New York University School of Medicine, New York, New York, USA scott.r.cutro@gmail.com

2Division of Infectious Diseases, New York University School of Medicine, New York, New York, USA.

3Department of Pharmacy, New York University-Langone Medical Center, New York, New York, USA.

Abstract

Piperacillin-tazobactam (PTZ) is frequently used as empirical and targeted therapy for Gram-negative sepsis. Time-dependent killing properties of PTZ support the use of extended-infusion (EI) dosing; however, studies have shown inconsistent benefits of EI PTZ treatment on clinical outcomes. We performed a retrospective cohort study of adult patients who received EI PTZ treatment and historical controls who received standard-infusion (SI) PTZ treatment for presumed sepsis syndromes. Data on mortality rates, clinical outcomes, length of stay (LOS), and disease severity were obtained. A total of 843 patients (662 with EI treatment and 181 with SI treatment) were available for analysis. Baseline characteristics of the two groups were similar, except for fewer female patients receiving EI treatment. No significant differences between the EI and SI groups in inpatient mortality rates (10.9% versus 13.8%; P = 0.282), overall LOS (10 versus 12 days; P = 0.171), intensive care unit (ICU) LOS (7 versus 6 days; P = 0.061), or clinical failure rates (18.4% versus 19.9%; P = 0.756) were observed. However, the duration of PTZ therapy was shorter in the EI group (5 versus 6 days; P < 0.001). Among ICU patients, no significant differences in outcomes between the EI and SI groups were observed. Patients with urinary or intra-abdominal infections had lower mortality and clinical failure rates when receiving EI PTZ treatment. We did not observe significant differences in inpatient mortality rates, overall LOS, ICU LOS, or clinical failure rates between patients receiving EI PTZ treatment and patients receiving SI PTZ treatment. Patients receiving EI PTZ treatment had a shorter duration of PTZ therapy than did patients receiving SI treatment, and EI dosing may provide cost savings to hospitals.

PDF

http://aac.asm.org/content/58/8/4470.full.pdf+html

August 25, 2016 at 8:19 am

Effect of meropenem administration in extended infusion on the clinical outcome of febrile neutropenia: a retrospective observational study

J Antimicrob Chemother. 2014 Sep;69(9):2556-62.

Fehér C1, Rovira M2, Soriano A3, Esteve J2, Martínez JA4, Marco F5, Carreras E2, Martínez C2, Fernández-Avilés F2, Suárez-Lledó M2, Mensa J4.

Abstract

OBJECTIVES:

Information on the efficacy of extended meropenem administration in neutropenic patients is scarce. Our objective was to determine whether the administration of meropenem in a 4 h extended infusion (EI) leads to a better clinical outcome in patients with febrile neutropenia than the conventional short infusion (SI).

METHODS:

This was a retrospective observational study. The subjects were neutropenic patients who presented with fever after receiving haematopoietic stem-cell transplantation or induction chemotherapy for acute myeloid leukaemia. The primary endpoint was the success of treatment after 5 days of meropenem therapy, defined as follows: the disappearance of fever leading to a maintained (≥ 24 h) feverless state; the resolution or improvement of the clinical signs and symptoms of infection; the absence of persistent or breakthrough bacteraemia; and no additional antibiotics prescribed because of an unsatisfactory clinical evolution.

RESULTS:

Eighty-eight patients received meropenem (1 g/8 h) in SI and 76 received the same dose in EI. Treatment success on day 5 was superior in the EI group [52/76 (68.4%) versus 36/88 (40.9%); P<0.001]. Meropenem administered in EI was independently associated with success (OR 3.13, 95% CI 1.61-6.10). Fewer additional antibiotics were prescribed in the EI group during the first 5 days of treatment [20/76 (26.3%) versus 44/88 (50.0%); P=0.002]. Using Kaplan-Meier survival analysis a more prompt defervescence and a faster decrease in C-reactive protein concentration were observed in the EI group (P=0.021 and P=0.037, respectively). There were no significant differences in the length of hospital stay and in the mortality rate.

CONCLUSIONS:

Meropenem administration in EI results in a better clinical outcome for febrile neutropenia episodes, with fewer additional antibiotics needed.

PDF

http://jac.oxfordjournals.org/content/69/9/2556.full.pdf+html

August 25, 2016 at 8:17 am

Immunization of Health-Care Providers: Necessity and Public Health Policies.

Healthcare (Basel). 2016 Aug 1;4(3).

Maltezou HC1, Poland GA2.

Author information

1Department for Interventions in Health-Care Facilities, Hellenic Center for Disease Control and Prevention, 3-5 Agrafon Street, Athens 15123, Greece. helen-maltezou@ath.forthnet.gr

2Mayo Clinic Vaccine Research Group, 611C Guggenheim Building, Mayo Clinic and Foundation, 200 First Street, SW Rochester, Rochester, MN 55905, USA. poland.gregory@mayo.edu

Abstract

Health-care providers (HCPs) are at increased risk for exposure to vaccine-preventable diseases (VPDs) in the workplace. The rationale for immunization of HCPs relies on the need to protect them and, indirectly, their patients from health-care-associated VPDs. Published evidence indicates significant immunity gaps for VPDs of HCPs globally. Deficits in knowledge and false perceptions about VPDs and vaccines are the most common barriers for vaccine uptake and may also influence communication about vaccines between HCPs and their patients. Most countries have immunization recommendations for HCPs; however, there are no universal policies and significant heterogeneity exists between countries in terms of vaccines, schedules, frame of implementation (recommendation or mandatory), and target categories of HCPs. Mandatory influenza immunization policies for HCPs have been implemented with high vaccine uptake rates. Stronger recommendations for HCP immunization and commitment at the level of the health-care facility are critical in order to achieve high vaccine coverage rates. Given the importance to health, mandatory immunization policies for VPDs that can cause serious morbidity and mortality to vulnerable patients should be considered

PDF (CLIC DOWNLOAD PDF)

http://www.mdpi.com/2227-9032/4/3/47

August 25, 2016 at 8:15 am

High MICs for Vancomycin and Daptomycin and Complicated Catheter-Related Bloodstream Infections with Methicillin-Sensitive Staphylococcus aureus.

Emerg Infect Dis. 2016 Jun;22(6):1057-66.

San-Juan R, Viedma E, Chaves F, Lalueza A, Fortún J, Loza E, Pujol M, Ardanuy C, Morales I, de Cueto M, Resino-Foz E, Morales-Cartagena A, Rico A, Romero MP, Orellana MÁ, López-Medrano F, Fernández-Ruiz M, Aguado JM.

Abstract

We investigated the prognostic role of high MICs for antistaphylococcal agents in patients with methicillin-sensitive Staphylococcus aureus catheter-related bloodstream infection (MSSA CRBSI). We prospectively reviewed 83 episodes from 5 centers in Spain during April 2011-June 2014 that had optimized clinical management and analyzed the relationship between E-test MICs for vancomycin, daptomycin, oxacillin, and linezolid and development of complicated bacteremia by using multivariate analysis. Complicated MSSA CRBSI occurred in 26 (31.3%) patients; MICs for vancomycin and daptomycin were higher in these patients (optimal cutoff values for predictive accuracy = 1.5 μg/mL and 0.5 μg/mL). High MICs for vancomycin (hazard ratio 2.4, 95% CI 1.2-5.5) and daptomycin (hazard ratio 2.4, 95% CI 1.1-5.9) were independent risk factors for development of complicated MSSA CRBSI. Our data suggest that patients with MSSA CRBSI caused by strains that have high MICs for vancomycin or daptomycin are at increased risk for complications.

PDF

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4880091/pdf/15-1709.pdf

August 24, 2016 at 8:37 am

Comparison of outcomes in patients with methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia who are treated with β-lactam vs vancomycin empiric therapy: a retrospective cohort study.

BMC Infect Dis. 2016 May 23;16(1):224.

Wong D1, Wong T2,3, Romney M2,4, Leung V2,4.

Author information

1PGY-V Infectious Diseases Residency Training Program, University of British Columbia, Vancouver General Hospital, D 452 Heather Pavilion, 2733 Heather Street, Vancouver, BC, V5Z 1 M9, Canada. wongdavi@mail.ubc.ca.

2Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada.

3Division of Medical Microbiology and Infection Control, Vancouver General Hospital, JPPN1, Medical Microbiology Laboratory, 899 W 12th Ave, Vancouver, BC, V5Z 1 M9, Canada.

4Division of Medical Microbiology, St. Paul’s Hospital, Medical Microbiology Laboratory, 1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada.

Abstract

BACKGROUND:

Prior studies suggested that vancomycin may be inferior to β-lactams for the empiric treatment of methicillin-susceptible S. aureus (MSSA) bacteremia. We assessed whether empiric therapy with β-lactams compared to vancomycin was associated with differences in clinical outcomes in patients with MSSA bacteremia.

METHODS:

We conducted a retrospective cohort study of adult inpatients with their first episode of MSSA bacteremia at two tertiary care hospitals in Vancouver, Canada, between 2007 and 2014. Exposure was either empiric β-lactam or vancomycin therapy. All patients received definitive treatment with cloxacillin or cefazolin. The primary outcome was 28-day mortality. Secondary outcomes were 90-day mortality, recurrent infection at 6 months, duration of bacteremia and hospital length-of-stay. Outcomes were adjusted using multivariable logistic regression.

RESULTS:

Of 814 patients identified, 400 met inclusion criteria (β-lactam = 200, vancomycin = 200). Overall 28-day mortality was 8.5 % (n=34). There were more cases of infective endocarditis in the β-lactam than in the vancomycin group [45 (22.5 %) vs 23 (11.5 %), p < 0.01]. Adjusted mortality at 28 days was similar between the two groups (OR: 1.14; 95 % CI: 0.49-2.64). No differences in secondary outcomes were observed. Transition to cloxacillin or cefazolin occurred within a median of 67.8 h in the vancomycin group.

CONCLUSIONS:

Empiric therapy with β-lactams was not associated with differences in all-cause mortality, recurrent infection, microbiological cure or hospital length-of-stay compared to vancomycin. Vancomycin monotherapy may be appropriate for the empiric treatment of MSSA bacteremia if definitive therapy with cloxacillin or cefazolin can be initiated within 3 days

PDF

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4878066/pdf/12879_2016_Article_1564.pdf

August 24, 2016 at 8:36 am

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