Posts filed under ‘Antimicrobianos’

Emergence of dominant toxigenic M1T1 Streptococcus pyogenes clone during increased scarlet fever activity in England: a population-based molecular epidemiological study

The Lancet Infectious Diseases September 10, 2019

Background

Since 2014, England has seen increased scarlet fever activity unprecedented in modern times. In 2016, England’s scarlet fever seasonal rise coincided with an unexpected elevation in invasive Streptococcus pyogenes infections. We describe the molecular epidemiological investigation of these events.

Methods

We analysed changes in S pyogenes emm genotypes, and notifications of scarlet fever and invasive disease in 2014–16 using regional (northwest London) and national (England and Wales) data. Genomes of 135 non-invasive and 552 invasive emm1 isolates from 2009–16 were analysed and compared with 2800 global emm1 sequences. Transcript and protein expression of streptococcal pyrogenic exotoxin A (SpeA; also known as scarlet fever or erythrogenic toxin A) in sequenced, non-invasive emm1 isolates was quantified by real-time PCR and western blot analyses.

Findings

Coincident with national increases in scarlet fever and invasive disease notifications, emm1 S pyogenes upper respiratory tract isolates increased significantly in northwest London in the March to May period, from five (5%) of 96 isolates in 2014, to 28 (19%) of 147 isolates in 2015 (p=0·0021 vs 2014 values), to 47 (33%) of 144 in 2016 (p=0·0080 vs 2015 values). Similarly, invasive emm1 isolates collected nationally in the same period increased from 183 (31%) of 587 in 2015 to 267 (42%) of 637 in 2016 (p<0·0001). Sequences of emm1 isolates from 2009–16 showed emergence of a new emm1 lineage (designated M1UK)—with overlap of pharyngitis, scarlet fever, and invasive M1UK strains—which could be genotypically distinguished from pandemic emm1 isolates (M1global) by 27 single-nucleotide polymorphisms. Median SpeA protein concentration in supernatant was nine-times higher among M1UK isolates (190·2 ng/mL [IQR 168·9–200·4]; n=10) than M1global isolates (20·9 ng/mL [0·0–27·3]; n=10; p<0·0001). M1UK expanded nationally to represent 252 (84%) of all 299 emm1 genomes in 2016. Phylogenetic analysis of published datasets identified single M1UK isolates in Denmark and the USA.

Interpretation

A dominant new emm1 S pyogenes lineage characterised by increased SpeA production has emerged during increased S pyogenes activity in England. The expanded reservoir of M1UK and recognised invasive potential of emm1 S pyogenes provide plausible explanation for the increased incidence of invasive disease, and rationale for global surveillance.

Funding

UK Medical Research Council, UK National Institute for Health Research, Wellcome Trust, Rosetrees Trust, Stoneygate Trust.

FULL TEXT

https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(19)30446-3/fulltext

PDF

https://www.thelancet.com/action/showPdf?pii=S1473-3099%2819%2930446-3

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September 13, 2019 at 7:30 am

Intraoperative povidone-iodine irrigation for infection prevention

Arthroplasty Today September 2019 V.5 N.3 P.306-308

Although prevention of infection following arthroplasty requires a multifaceted approach, the use of intraoperative irrigation is an important component of any protocol.

Recent clinical practice guidelines from the Centers for Disease Control, World Health Organization, and International Consensus Meeting on Musculoskeletal Infection advocate the use of a dilute povidone-iodine solution prior to wound closure.

Our experience suggests that this practice is safe, inexpensive, and easily implemented.

The present article describes our institutional irrigation protocol and reviews the current literature regarding povidone-iodine solutions.

FULL TEXT

https://www.arthroplastytoday.org/article/S2352-3441(19)30037-8/fulltext?_cldee=ZmVybmFuZG9sb3ByZWl0ZUBob3RtYWlsLmNvbQ%3d%3d&recipientid=contact-735e0277de7de71186420050569142af-587751a5c70a434085280eb593298179&utm_source=ClickDimensions&utm_medium=email&utm_campaign=AAHKS%20News&esid=f4b972ed-02d0-e911-80fc-000d3a03faaf

PDF

https://www.arthroplastytoday.org/article/S2352-3441(19)30037-8/pdf

September 6, 2019 at 8:17 am

Single-Dose Perioperative Antibiotics Do Not Increase the Risk of Surgical Site Infection in Unicompartmental Knee Arthroplasty

Journal of Arthroplasty July 2019 V.34 Supplement S327–S330

Background

Unicompartmental knee arthroplasty (UKA) is commonly performed as an outpatient procedure. To facilitate this process, a single-dose intravenous (IV) perioperative antibiotic administration is required compared to 24-hour IV antibiotic dosing schedules that are typical of most inpatient arthroplasty procedures. There is a paucity of literature to guide surgeons on the safety of single-dose perioperative antibiotic administration for arthroplasty procedures, particularly those that will be performed in the outpatient setting. The purpose of this study is to evaluate a large series of UKA performed with single-dose vs 24-hour IV antibiotic coverage to determine the impact on risk for surgical site infection (SSI).

Methods

All UKA cases were evaluated from 2007 to 2017 performed by a single surgeon at an academic institution. There were 296 UKAs in the cohort: 40 were outpatient procedures receiving single-dose antibiotics and 256 were inpatient procedures receiving 24-hour antibiotics. No patients were prescribed adjuvant oral antibiotics. Mean age was 64 years, 50% were female, mean body mass index was 32 kg/m2, and mean follow-up was 4.1 years (range 1.0-10.4). Perioperative antibiotic regimen was evaluated and SSI, defined as occurring within 1 year of surgery, was abstracted through a prospective total joint registry and manual chart review.

Results

SSI occurred in 2 of 296 cases (0.7%) in the entire cohort, 2 of 256 inpatient UKAs (0.8%), and 0 of 40 outpatient UKAs (0%) (P = 1.00). One SSI was a deep infection occurring 6 weeks postoperatively that required 2-stage exchange and conversion to total knee arthroplasty. The other was a superficial infection treated with 2 weeks of oral antibiotics.

Conclusion

This study demonstrates a low SSI risk (0.8% or less) following UKA with both single-dose and 24-hour IV antibiotics. Administering single-dose perioperative antibiotics is safe for UKA, which should alleviate that potential concern for outpatient surgery.

FULL TEXT

https://www.arthroplastyjournal.org/article/S0883-5403(19)30197-4/fulltext

PDF

https://www.arthroplastyjournal.org/article/S0883-5403(19)30197-4/pdf

August 30, 2019 at 4:15 pm

Traditional Laboratory Markers Hold Low Diagnostic Utility for Immunosuppressed Patients With Periprosthetic Joint Infections

Journal of Arthroplasty July 2019 V.34 N.7 P.1441–1445

Background

Although predictive laboratory markers and cutoffs for immunocompetent patients are well-studied, similar reference ranges and decision thresholds for immunosuppressed patients are less understood. We investigated the utility of typical laboratory markers in immunosuppressed patients undergoing aspiration of a prosthetic hip or knee joint.

Methods

A retrospective review of adult patients with an immunosuppressed state that underwent primary and revision total joint arthroplasty with a subsequent infection at our tertiary, academic institution was conducted. Infection was defined by Musculoskeletal Infection Society criteria. A multivariable analysis was used to identify independent factors associated with acute (<90 days) and chronic (>90 days) infection. Area under the receiver-operator curve (AUC) was used to determine the best supported laboratory cut points for identifying infection.

Results

We identified 90 patients with immunosuppression states totaling 172 aspirations. Mean follow-up from aspiration was 33 months. In a multivariate analysis, only synovial fluid cell count and synovial percent neutrophils were found to be independently correlated with both acute and chronic infection. A synovial fluid cell count cutoff value of 5679 nucleated cells/mm3 maximized the AUC (0.839) for predicting acute infection, while a synovial fluid cell count cutoff value of 1293 nucleated cells/mm3 maximized the AUC (0.931) for predicting chronic infection.

Conclusion

Physicians should be aware of lower levels of synovial nucleated cell count and percentage of neutrophils in prosthetic joint infections of the hip or knee in patients with immunosuppression. Further investigation is necessary to identify the best means of diagnosing periprosthetic joint infection in this patient population.

FULL TEXT

https://www.arthroplastyjournal.org/article/S0883-5403(19)30236-0/fulltext

PDF

https://www.arthroplastyjournal.org/article/S0883-5403(19)30236-0/pdf

August 30, 2019 at 4:10 pm

The Presence of Sinus Tract Adversely Affects the Outcome of Treatment of Periprosthetic Joint Infections

Journal of Arthroplasty June 2019 V.34 N.6 P.1227-1232

Background

A sinus tract may be encountered in patients with periprosthetic joint infection (PJI) and constitutes a major criterion for diagnosis. The aim of this study is to identify associated factors for the presence of sinus tract and outcome of 2-stage exchange arthroplasty in these patients.

Methods

We retrospectively reviewed all patients with PJI following hip and knee arthroplasty from 2000 to 2017. Of them, 161 patients with a sinus tract had a minimum follow-up of 1 year following 2-stage exchange arthroplasty. These patients were matched 1:2 with those without sinus tract by using propensity score matching. Treatment success was assessed using the modified Delphi criteria. A multiple logistic regression analysis was performed to determine the effect of sinus tract on the outcome and associated factors for the presence of sinus tract.

Results

Factors significantly associated with sinus tract included smoking (odds ratio [OR] = 1.83), hypothyroidism (OR = 1.62), hypoalbuminemia (OR = 1.52), hip joint involvement (OR = 1.43), and prior revision surgery (OR = 1.37). Patients with sinus tract had a significantly higher rate of failure compared to those without sinus tract (OR = 2.94).

Conclusion

This study demonstrates that the presence of sinus tract in patients with PJI adversely affects the outcome of treatment of these patients. The presence of sinus tract may be a proxy for other issues such as poor periarticular soft tissue, the poor nutritional status of the host, and multiple prior operations. These findings need to be borne in mind when treating patients with PJI and a concomitant sinus tract.

FULL TEXT

https://www.arthroplastyjournal.org/article/S0883-5403(19)30196-2/fulltext

PDF

https://www.arthroplastyjournal.org/article/S0883-5403(19)30196-2/pdf

August 30, 2019 at 4:08 pm

Clinical Klebsiella pneumoniae Isolate with Three Carbapenem Resistance Genes Associated with Urology Procedures – King County, Washington, 2018.

MMWR Morb Mortal Wkly Rep. 2019 Aug 2;68(30):667-668.

Vannice K, Benoliel E, Kauber K, Brostrom-Smith C, Montgomery P, Kay M, Walters M, Tran M, D’Angeli M, Duchin J.

PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6677168/pdf/mm6830a4.pdf

August 29, 2019 at 6:12 pm

Fever and Erythema are Specific Findings in Detecting Infection Following Total Knee Arthroplasty.

J Bone Jt Infect. March 16, 2019 V.4 B.2 P.92-98. doi: 10.7150/jbji.30088. eCollection 2019.

Shohat N1,2, Goswami K1, Tan TL1, Henstenburg B1, Makar G1, Rondon AJ1, Parvizi J1.

1 The Rothman Institute at Thomas Jefferson University, Philadelphia, PA 19107.

2 Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.

Abstract

Current diagnostic modalities are based almost exclusively on laboratory findings and the role of clinical presentation remains unknown. The purpose of this study was to examine the diagnostic value of clinical presentation in detecting periprosthetic joint infection (PJI). This study evaluated 279 patients undergoing revision surgery for failed total knee arthroplasty (TKA) between 2001-2016. Patients were classified as undergoing septic revisions based on major MSIS criteria. Aseptic revisions were defined as cases of single stage revision that did not have suspected PJI, fulfill MSIS criteria, or subsequently fail within one year of follow-up. Clinical presentation included pain, fever, presence of joint effusion or erythema, and reduced range of motion. Serum and synovial laboratory markers were also evaluated. The diagnostic value of each test was assessed and a Fagan’s nomogram was constructed. A subset of MSIS-negative patients was used to demonstrate the value of various clinical presentations in detecting PJI. Post-test probability for infection was calculated taking into account clinical presentation together with serum and synovial markers. Our results show that fever and erythema are the most important signs for diagnosing PJI with a positive likelihood ratio (LR) of 10.78 and 8.08, respectively. Effusion had a LR of 2.42. Pain and reduced ROM were not as strongly correlated with PJI diagnosis; LR was 1.02 and 1.51. Of the 35 MSIS-negative patients treated for PJI, 33 had a post-test probability of infection greater than 90% when taking clinical presentation into account. Clinical presentation should be used to guide which future diagnostic tests should be ordered and in the interpretation of their results. Our results indicate that pain, fever, presence of joint effusion or erythema, and reduced range of motion should prompt further workup for infection. We propose a nomogram that may be used in interoperating their individual weight together with laboratory findings. Fever and erythema are highly specific findings in patients with PJI and future studies should assess whether they may be added as minor criteria to current definitions for infection.

PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6470654/pdf/jbjiv04p0092.pdf

August 28, 2019 at 3:52 pm

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