Posts filed under ‘FIEBRE en el POSTOPERATORIO’
Epidemiology of intra-abdominal infection and sepsis in critically ill patients: “AbSeS”, a multinational observational cohort study and ESICM Trials Group Project
Intensive Care Medicine December 2019 V.45 N.12 P.1703–1717
Blot, S., Antonelli, M., Arvaniti, K. et al
Propósito
Para describir la epidemiología de la infección intraabdominal (IIA) en una cohorte internacional de pacientes de UCI de acuerdo con un nuevo sistema que clasifica los casos según el contexto de:
adquisición de infección (adquirida en la comunidad, adquirida en el hospital de inicio temprano y adquirida en el hospital de inicio tardío),
disrupción anatómica (ausente o presente con peritonitis localizada o difusa) y
gravedad de la expresión de la enfermedad (infección, sepsis y shock séptico).
Métodos
Realizaron un estudio epidemiológico, multicéntrico (n = 309) que incluyó pacientes adultos en UCI diagnosticados con IIA. Los FR de mortalidad se evaluaron mediante análisis de regresión logística.
Resultados
La cohorte incluyó 2621 pacientes.
El contexto de adquisición de infección:
adquirida en la comunidad en el 31,6%,
adquirida en el hospital de inicio temprano en el 25% y
adquirida en el hospital de inicio tardío en el 43,4% de los pacientes.
La prevalencia general de la RAM fue del 26,3% y la de BGN-MR del 4,3%, con una gran variación según la región geográfica. No se observaron diferencias en la prevalencia de RAM según el contexto de adquisición de la infección.
La mortalidad global fue del 29,1%.
Los FR independientes para la mortalidad incluyeron:
infección adquirida en el hospital de inicio tardío,
peritonitis difusa,
sepsis,
shock séptico,
edad > 65 años,
desnutrición,
insuficiencia hepática,
insuficiencia cardíaca congestiva,
RAM (SAMR, EVR, BGN productores de BLEE, o BGN carbapenem-R y
la falla del control de la fuente evidenciada por la necesidad de revisión quirúrgica o inflamación persistente.
Conclusión
Esta cohorte multinacional y heterogénea de pacientes de UCI con IIA reveló que el contexto de adquisición de infección, alteración anatómica y gravedad de la expresión de la enfermedad son características fenotípicas específicas de la enfermedad asociada con el resultado, independientemente del tipo de infección. La RAM es igualmente común en la infección adquirida en la comunidad como en la adquirida en el hospital.
FULL TEXT
https://link.springer.com/article/10.1007%2Fs00134-019-05819-3#Abs1
https://link.springer.com/content/pdf/10.1007%2Fs00134-019-05819-3.pdf
Dalbavancin for treating prosthetic joint infections caused by Gram-positive bacteria: A proposal for a low dose strategy. A retrospective cohort study
Revista Española de Quimioterapia Diciembre 2019 V.32 N.6 P.532-538
Introducción.
Las bacterias grampositivas son la principal causa de infección periprotésica (IPP). Dalbavancina es un lipoglicopéptido con interesantes propiedades farmacocinéticas y una importante actividad bactericida frente a la mayoría de gram positivos. Aunque aún necesitamos mayor evidencia en relación con su uso en infección osteoarticular, estudios recientes sugieren un papel importante de dalbavancina en la IPP.
Métodos.
Desde el 1 de Junio de 2016 al 1 de Mayo de 2018, todos los pacientes diagnosticados con IPP y tratados con dalbavancina sola o en combinación con otros fármacos fueron evaluados de forma retrospectiva. La sensibilidad a dalbavancina de los aislamientos fue evaluada según las recomendaciones de CLSI. El objetivo primario fue determinar la eficacia y tolerabilidad del fármaco en pacientes con IPP. Se realizó un análisis de coste siguiendo la metodología descrita en el estudio DALBUSE.
Resultados.
Dieciséis pacientes fueron tratados con dalbavancina, ocho con infección de prótesis total de cadera y ocho con infección de prótesis total de rodilla. Staphylococcus spp. y Enterococcus spp. fueron los microorganismos implicados. No hubo efectos adversos relevantes. La infección se resolvió en 12 pacientes. En dos pacientes el tratamiento falló, y otro paciente falleció por causas no relacionadas. Un paciente es actualmente en tratamiento supresor por infección por diseminación hematógena de prótesis total de rodilla a partir de endocarditis protésica aórtica. Tras la discontinuación de dalbavancina, y exceptuando los pacientes fallecidos y/o con fallo terapéutico, el seguimiento medio fue de 503 dias (rango intercuartílico 434.5-567 dias). Se estimó un ahorro de 264.769 dólares USA.
Conclusiones.
Este estudio sugiere que dalbavancina para el tratamiento de IPP causada por microorganismos gram positivos es segura y una opción eficaz que reduce la estancia hospitalaria y los costes. Se precisan más comunicaciones para confirmar estos datos.
https://seq.es/wp-content/uploads/2019/10/buzon22oct2019.pdf
Dilute Povidone-Iodine Solution Prevents Intraoperative Contamination of Sterile Water Basins During Total Joint Arthroplasty
Journal of Arthroplasty January 2020 V.35 N.1 P.241–246
Background
Periprosthetic joint infection is a major complication of total joint arthroplasty (TJA). The intraoperative splash basin has been found to be a potential source of contamination. Although consensus recommendations against the use of splash basin have been made, splash basin use continues to be taught and utilized in practice. This study aims to investigate the effect of dilute betadine addition to the sterile water (SW) contents (0.02% solution) of the splash basin on contamination rates. This intervention could preserve the functionality and preferential use of the splash basin. The primary outcome of this study is the rate of splash basin contamination, with secondary outcomes of prevalence of culture speciation and mean operative times association with the rate of positive cultures.
Methods
Patients undergoing primary TJA were enrolled in a randomized controlled trial with assignment to either the intervention/betadine group, in which dilute betadine was added to the standard SW splash basin, or the control/standard SW group. For a total cohort of 104 patients, a 120 mL aliquot sample of basin fluid was collected at incision (“preprocedure”) and closure (“postprocedure”). Samples were cultured and monitored for 48 hours for growth, with further testing as necessary to identify microbial speciation.
Results
Of the final 100 postprocedure samples, 0 (0.0%) were positive in the betadine group, while there were 23 (47.9%) positive samples in the SW group (P < .001). Of the positive cultures, the most common species grown were coagulase-negative Staphylococcus, Corynebacterium, and Micrococcus. The mean operative time was an average of 11 minutes longer for cases with positive cultures.
Conclusion
In conclusion, treating SW splash basins with dilute povidone-iodine (0.02% solution) eliminates intraoperative contamination of splash basins in TJA procedures. This intervention is simple, low cost, and readily implementable, making it a reasonable addition to TJA protocols.
Level of Evidence
Level 1, Controlled Laboratory Study.
https://www.arthroplastyjournal.org/article/S0883-5403(19)30747-8/pdf
Differences in Diagnostic Properties Between Standard and Enrichment Culture Techniques Used in Periprosthetic Joint Infections
Journal of Arthroplasty January 2020 V.35 N.1 P.235–240
Background
Culture-negative infections can complicate the diagnosis and management of orthopedic infections, particularly periprosthetic joint infections (PJIs). This study aimed to identify differences in rate of detection of infection and organisms between cultured using standard and enriched methods.
Methods
This retrospective, cross-sectional study evaluated PJI samples obtained between January 2013 and December 2017 at Yokohama City University Hospital. Samples were assessed using standard and enrichment culture techniques. White blood cell counts, C-reactive protein levels, type of microorganism (coagulase-positive or coagulase-negative), and methicillin-resistant Staphylococcus were investigated.
Results
A total of 151 PJI samples were included in the analysis; of these, 68 (45.0%) were positive after standard culture while 83 (55.0%) were positive only after enrichment culture. The mean white blood cell counts and C-reactive protein levels were significantly lower in the enrichment culture group than in the standard culture group (P < .01). The rate of methicillin-resistant Staphylococcus and coagulase-negative Staphylococci was significantly higher in the enrichment culture group than in the standard culture group (P < .01).
Conclusion
The enrichment culture method has a higher rate of detection of infection than standard culture techniques and should, therefore, be considered when diagnosing orthopedic infections, particularly PJI.
https://www.arthroplastyjournal.org/article/S0883-5403(19)30766-1/pdf
Combined Measurement of D-Dimer and C-Reactive Protein Levels: Highly Accurate for Diagnosing Chronic Periprosthetic Joint Infection
Journal of Arthroplasty January 2020 V.35 N.1 P.229–234
Background
Diagnosis of chronic periprosthetic joint infection (PJI) can be challenging and elusive in the absence of a gold standard. D-dimer plays an important role in inflammation that occurs during infections and therefore could be a valuable biomarker for PJI. This study aims to investigate the sensitivity and specificity of D-dimer in detecting chronic PJI and to improve the accuracy of chronic PJI diagnosis through combined measurement of serum D-dimer with C-reactive protein (CRP)/erythrocyte sedimentation rate.
Methods
One hundred twenty-two patients presenting with a painful knee or hip after total hip or total knee arthroplasty for surgical revision were included in this prospective trial. Our cohort consisted of 55 patients undergoing revision for chronic PJI and 67 patients undergoing revision for aseptic failure. PJI was defined using the Musculoskeletal Infection Society criteria. Receiver operating characteristic curves and area under the curve were analyzed for each biomarker.
Results
The area under the curve for D-dimer was 0.915 and was more accurate than serum erythrocyte sedimentation rate 0.719 and CRP 0.761. 1170 ng/mL was determined to be the optimal threshold value of D-dimer for the diagnosis of chronic PJI, with a sensitivity of 92.73% and a specificity of 74.63% in the diagnosis of chronic PJI. The combination of D-dimer and CRP tests demonstrated a sensitivity of 98.11% and negative predictive value of 96.55% for the diagnosis of chronic PJI.
Conclusion
The present study identified the D-dimer is a valuable biomarker in detecting chronic PJI. The combinations of serum D-dimer and CRP led to the improvement of sensitivity compared with those of the single-index test.
https://www.arthroplastyjournal.org/article/S0883-5403(19)30743-0/pdf
Bone and Joint Infections among Hematopoietic Stem Cell Transplant Recipients.
Journal of Bone and Joint Infection September 18, 2019 V.4 N.5 P.209-215.
Abad CL1, Phuoc V2, Kapoor P3, Tosh PK4, Sia IG4, Osmon DR4, Tande AJ4.
Author information
1 Department of Internal Medicine, Section of Infectious Diseases, University of the Philippines-Manila, Philippine General Hospital, Manila Philippines.
2 Division of Hematology, University of the Philippines-Manila, Philippine General Hospital, Manila Philippines.
3 Division of Infectious Diseases, University of the Philippines-Manila, Philippine General Hospital, Manila Philippines.
4 Mayo Clinic, Rochester MN, USA.
Abstract
Background:
Hematopoietic stem cell transplantation (HSCT) recipients are at increased risk for infection. This study describes bone and joint infections (BJI) among HSCT recipients.
Methods:
We reviewed 5861 patients who underwent HSCT at Mayo Clinic, Rochester, MN from January 1, 2005 through January 1, 2015 for study inclusion. BJI was defined as native septic arthritis, prosthetic joint infection, osteomyelitis, and orthopedic implant infection. All adults with BJI after HSCT were included in the analysis.
Results:
Of 5861 patients, 33 (0.6%) developed BJI. Native joint septic arthritis was the most common BJI occurring in 15/33 (45.4%) patients. Patients were predominantly male (24/33, 72.7%), with median age of 58 (range 20-72) years. BJI was diagnosed a median of 39 (range 1-114) months after allogeneic (14/33, 42.4%) or autologous (19/33, 57.6%) HSCT. Organisms were recovered via tissue (24/27, 88.9%), synovial fluid (13/17, 76.5%), and/or blood cultures (16/25, 64%). Most underwent surgical debridement (23/33, 69.7%). Patients were followed a median of 78.3 months (range 74-119). Therapy was unsuccessful in 4/33 (12.1%), with death related to the underlying BJI in two (50%). Failure occurred a median of 3.4 (0.1-48.5) months from diagnosis. At last follow up, 7/33 (21.2%) patients were alive. Median overall survival was 13 months (0.07-70.6).
Conclusion:
BJI among HSCT recipients is infrequent. The most common infection is native joint septic arthritis. Pathogens appear similar to patients without HSCT. Treatment involving surgical-medical modalities is successful, with most patients surviving >1 year after BJI.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6831805/pdf/jbjiv04p0209.pdf
Prosthetic Joint Infection due to Actinomyces species: A case series and review of literature.
Journal of Bone and Joint Infection August 2, 2019 V.4 N.4 P.174-180.
Dagher R1, Riaz T1, Tande AJ1, Osmon DR1, Jagtiani A1, Steckelberg JM1, Mabry T2, Berbari EF1.
Author information
1 Department of Internal Medicine and Division of Infectious Diseases, Mayo Clinic College of Medicine, 200 1st Street SW, Rochester, MN 55905.
2 Department of Orthopedic Surgery, Mayo Clinic College of Medicine, 200 1st Street SW, Rochester, MN 55905.
Abstract
Background:
Actinomyces prosthetic joint infections (APJIs) are rare and optimal medical and surgical treatment strategies are unknown. The purpose of our study was to characterize the demographics, risk factors, management and outcomes of patients with PJIs due to Actinomyces spp.
Methods:
Using a retrospective cohort study design, the medical records of all patients with Actinomyces spp. total hip or knee arthroplasty infection (APJI) seen at a single institution between January 1, 1969 and December 31, 2016 were reviewed. We abstracted information including patient demographics, co-morbidities, joint age, surgical history, microbiology, management and outcomes. A simultaneous literature search via PubMed was performed to identify cases of APJI published in literature and a descriptive analysis was performed.
Results:
Eleven cases were identified over a 47 year study period at our institution. Seven patients (64%) were female. The median age at the time of diagnosis of infection was 71 years (range, 57-89). The knee was involved in six cases (55%) followed by the hip in 5 (45 %) cases. Three cases had dentures, broken teeth, or poor dentition. Actinomyces odonotlyticus was the most commonly found subspecies at our institution. Median ESR and CRP values were 61mm/hr and 64 mg/L respectively. Eight (72%) patients were managed with 2 stage exchange. Most patients received a course of beta-lactam therapy for 6 weeks. Ten cases (91%) were free of failure after a median duration of follow-up of 2 years (range, 0.67 – 5 years). The median duration from joint arthroplasty to the onset of symptoms was 162 days, range (20-3318). Six (54%) had a history of prior PJI with a different microorganism at the same joint site and 4 patients had history of prior 2 stage exchange (36%). In the literature group, we identified 12 cases and the most common subspecies was Actinomyces israelii; most patients underwent two stage exchange and were treated with 6 weeks of beta lactam antibiotics.
Conclusions:
Based on our observational study, Actinomyces PJI presents as a late complication of TJR, may be associated with prior PJI at the index joint and antecedent dental manipulation may portend as an additional risk factor. Treatment includes two stage exchange and beta- lactam therapy for 6weeks. These results will help clinicians in improved understanding and management of APJIs which although are rare but warrant special attention as population with implanted joint arthroplasties continues to rise.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6757008/pdf/jbjiv04p0174.pdf
