Posts filed under ‘Infecciones osteo-articulares-musculares’

Chile: Primer reporte de colonización por Candida auris uris en un paciente procedente de India

Sociedad Chilena de Infectología

Microbiólogos e infectólogos del Hospital del Salvador, de Santiago, reportaron el 1er aislamiento en Chile de Candida auris en un paciente de nacionalidad india y radicado en Chile hace 30 años. El paciente es diabético tipo II de larga data.

En agosto 2018 evolucionó con signos de isquemia y posteriormente necrosis del 4to dedo izquierdo asociado a celulitis del mismo pie.

Sus familiares decidieron el traslado a Mumbay (India), para su tratamiento.

Fue amputado en un hospital en Mumbay el 20/agosto/2018. Completó 24 días de hospitalización por dificultad en el manejo de su diabetes mellitus, y posteriormente continuó con curaciones ambulatorias en el mismo centro.

Una semana antes de volver a Chile, en octubre 2018, notó signos compatibles con necrosis en la falange distal del 3er dedo ipsilateral.

Consultó a su regreso a Chile en el Servicio de Urgencia de un centro privado. Fue derivado al Hospital del Salvador, donde se estudió y derivó a cirugía vascular para amputación del 3er y 5to dedos  izquierdos con diagnóstico de pie diabético con complicaciones vasculares, sin signos de infección.

El 26/diciembre/2018 ingresó a pabellón, donde se tomaron cultivos de tejido del lecho de amputación y de una úlcera plantar en relación a la base del 5to dedo.

Luego de 48 hs de incubación no hubo crecimiento de colonias en el cultivo corriente, por lo que se realizó un traspaso final desde el caldo tioglicolato a un agar sangre.

El 31/12/2018 se estudió una colonia blanca pequeña, la que es identificada como Kokuria kristinae (98% de concordancia). Se realizó tinción de Gram de dicha colonia, observándose levaduras.

El 2/enero/2019 se procesó nuevamente, dando como resultado C. auris con 99% de concordancia.

En función de los resultados obtenidos, se envió la cepa al Instituto de Salud Pública (ISP), quien el 17/enero/2019 confirmó la identificación.

El paciente no fue tratado con antifúngicos debido a que este hallazgo fue interpretado como una colonización, al no existir síntomas ni signos inflamatorios en el sitio quirúrgico.

En controles posteriores, un mes después de la amputación, se evidenciaron elementos compatibles con infección del sitio quirúrgico (ISQ) realizándose toilette de la zona en la cual se aislaron Klebsiella pneumoniae (en tejido óseo y partes blandas) y Staphylococcus aureus (partes blandas), pero no se ha vuelto a aislar C. auris en muestras de tejido y hueso del paciente.

Producto del patrón de susceptibilidad de los agentes identificados, se hospitalizó para tratamiento ATB IV, siendo sometido finalmente a una amputación trans-metatarsiana el 19/febrero/2019.

En dicho procedimiento se tomaron cultivos óseos y de tejidos blandos adyacentes con resultados negativos.

Durante esta hospitalización, se obtuvieron hisopados nasal, orofaríngeo, axilar e inguinorrectal para estudio de portación de C. auris, con resultados negativos.

Para los procesos de atención clínica, el paciente fue manejado con precauciones de contacto (unidad individual, uso de elementos de protección personal, aseo de unidad supervisado de acuerdo a protocolo interno).

Candida auris es un hongo emergente considerado una seria amenaza para la salud pública. La preocupación mundial por C. auris se debe principalmente a tres razones:

1) la resistencia que presenta a múltiples antifúngicos comúnmente utilizados para tratar las infecciones por Candida;

2) los errores en la identificación con los métodos de laboratorio estándar;

3) ser causa de brotes intrahospitalarios en los cinco continentes.

Por esta razón, es importante identificar rápidamente la presencia de C. auris en un paciente hospitalizado, para que se puedan tomar las precauciones especiales para detener su propagación. Dado el gran potencial de diseminación de esta Candida, es muy importante reforzar las medidas de control para reducir el riesgo de transmisión.

Fuente:

Primer reporte en Chile de colonización por Candida auris en un paciente procedente de India.

Sociedad Chilena de Infectología (Chile)

PDF

http://www.sochinf.cl/portal/templates/sochinf2008/documentos/2019/Primer_reporte_Chile_colonizacion_Candida_auris_India.pdf

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April 15, 2019 at 8:35 am

RECOMENDACIONES PARA LA PREVENCIÓN DE INFECCIONES ASOCIADAS A ARTOPLASTIA ELECTIVA EN ADULTOS

Medicina (Buenos Aires). 2017 V.77 N.2 P.143-157

JUAN CARLOS CHULUYÁN1*, ANDREA VILA2*, ANA LAURA CHATTÁS3*, MARCELO MONTERO3*, CLAUDIA PENSOTTI4*+, CLAUDIA TOSELLO5*, MARISA SÁNCHEZ6*, CECILIA VERA OCAMPO7*, GUILLERMINA KREMER8*, RODOLFO QUIRÓS8*, GUILLERMO A. BENCHETRIT9*,CAROLINA FERNANDA PÉREZ10*, ANA LAURA TERUSI11*, FRANCISCO NACINOVICH12*

1 Grupo de Trabajo Infectología, Hospital General de Agudos Dr. T. Álvarez,

2 Servicio de Infectología, Hospital Italiano de Mendoza,

3 Hospital General de Agudos Dr. Pirovano,

4 Clínica Monte Grande,

5 Hospital de Clínicas José de San Martín, UBA,

6 Hospital Italiano de Buenos Aires,

7 Sanatorio Dupuytren,

8 Hospital Universitario Austral,

9 Instituto de Investigaciones Médicas A. Lanari, UBA,

10 Policlínico del Docente-Centro Médico Huésped,

11 Instituto César Milstein,

12 Instituto Cardiovascular de Buenos Aires, Centros Médicos Dr. Stamboulian, Argentina

Las infecciones del sitio quirúrgico que complican las cirugías ortopédicas con implante prolongan la estadía hospitalaria y aumentan tanto el riesgo de readmisión como el costo de la internación y la mortalidad. Las presentes recomendaciones están dirigidas a:

(i) optimizar el cumplimiento de normas y la incorporación de hábitos en cada una de las fases de la cirugía, detectando factores de riesgo para infecciones del sitio quirúrgico potencialmente corregibles o modificables; y

(ii) adecuar la profilaxis antibiótica preoperatoria y el cuidado intra y postoperatorio.

PDF

http://www.medicinabuenosaires.com/PMID/28463223.pdf

April 13, 2019 at 12:39 pm

Executive summary: Diagnosis and Management of Prosthetic Joint Infection: clinical practice Guidelines by the Infectious Diseases Society of America (IDSA).

Clinical Infectious Diseases January 2013 V.56 N.1 P.1-10   doi: 10.1093/cid/cis966.

Osmon DR, Berbari EF, Berendt AR, et al.

These guidelines are intended for use by infectious disease specialists, orthopedists, and other healthcare professionals who care for patients with prosthetic joint infection (PJI). They include evidence-based and opinion-based recommendations for the diagnosis and management of patients with PJI treated with debridement and retention of the prosthesis, resection arthroplasty with or without subsequent staged reimplantation, 1-stage reimplantation, and amputation.

FULL TEXT

https://academic.oup.com/cid/article/56/1/1/419472

PDF (HACER CLIC en PDF)

 

Clinical Infectious Diseases January 2013 V.6 N.1 P.e1-e25   doi: 10.1093/cid/cis803.

Diagnosis and Management of Prosthetic Joint Infection: clinical practice Guidelines by the Infectious Diseases Society of America (IDSA).

Osmon DR, Berbari EF, Berendt AR, et al.

These guidelines are intended for use by infectious disease specialists, orthopedists, and other healthcare professionals who care for patients with prosthetic joint infection (PJI). They include evidence-based and opinion-based recommendations for the diagnosis and management of patients with PJI treated with debridement and retention of the prosthesis, resection arthroplasty with or without subsequent staged reimplantation, 1-stage reimplantation, and amputation.

FULL TEXT

https://academic.oup.com/cid/article/56/1/e1/415705

PDF (HACER CLIC en PDF)

March 30, 2019 at 5:17 pm

The prevention of Prosthetic Joint Infection (PJI)- 12 modifiable risk factors

The Bone & Joint Journal January 2019 V.101-B N.1 Suppl.A P.3-9

K. Alamanda, B. D. Springer

Aims

Prosthetic joint infection (PJI) remains a serious complication that is associated with high morbidity and costs. The aim of this study was to prepare a systematic review to examine patient-related and perioperative risk factors that can be modified in an attempt to reduce the rate of PJI.

Materials and Methods

A search of PubMed and MEDLINE was conducted for articles published between January 1990 and February 2018 with a combination of search terms to identify studies that dealt with modifiable risk factors for reducing the rate of PJI. An evidence-based review was performed on 12 specific risk factors: glycaemic control, obesity, malnutrition, smoking, vitamin D levels, preoperative Staphylococcus aureus screening, the management of anti-rheumatic medication, perioperative antibiotic prophylaxis, presurgical skin preparation, the operating room environment, irrigant options, and anticoagulation.

Results

Poor glycaemic control, obesity, malnutrition, and smoking are all associated with increased rates of PJI. Vitamin D replacement has been shown in preliminary animal studies to decrease rates of PJI. Preoperative Staphylococcus aureus screening and appropriate treatment results in decreased rates of PJI. Perioperative variables, such as timely and appropriate dosage of prophylactic antibiotics, skin preparation with chlorohexidine-based solution, and irrigation with dilute betadine at the conclusion of the operation, have all been associated with reduced rates of PJI. Similarly, aggressive anticoagulation and increased operating room traffic should be avoided to help minimize risk of PJI.

Conclusion

PJI remains a serious complication of arthroplasty. Surgeons should be vigilant of the modifiable risk factors that can be addressed in an attempt to reduce the risk of PJI.

FULL TEXT

https://online.boneandjoint.org.uk/doi/full/10.1302/0301-620X.101B1.BJJ-2018-0233.R1

PDF

https://online.boneandjoint.org.uk/doi/pdf/10.1302/0301-620X.101B1.BJJ-2018-0233.R1

 

January 20, 2019 at 11:06 am

Osteomyelitis Complicating Sacral Pressure Ulcers: Whether or Not to Treat With Antibiotic Therapy

Clinical Infectious Diseases January 15, 2019 V.68 N.2 P.338–342

EDITOR’S CHOICE

Darren Wong; Paul Holtom; Brad Spellberg

The treatment of osteomyelitis in patients with stage IV sacral pressure ulcers is controversial. We conducted a systematic literature review and did not find evidence of benefit of antibacterial therapy in this setting without concomitant surgical debridement and wound coverage. Furthermore, many patients with chronically exposed bone do not have evidence of osteomyelitis when biopsied, and magnetic resonance imaging may not accurately distinguish osteomyelitis from bone remodeling. The goal of therapy should be local wound care and assessment for the potential of wound closure. If the wound can be closed and osteomyelitis is present on bone biopsy, appropriate antibiotic therapy is reasonable. We find no data to support antibiotic durations of >6 weeks in this setting, and some authors recommend 2 weeks of therapy if the osteomyelitis is limited to cortical bone. If the wound will not be closed, we find no clear evidence supporting a role for antibiotic therapy.

FULL TEXT

https://academic.oup.com/cid/article/68/2/338/5050260

PDF (CLIC en PDF)

January 20, 2019 at 11:03 am

What Is the Role of Repeat Aspiration in the Diagnosis of Periprosthetic Hip Infection?

Journal of Arthropasty January 2019 V.34 N.1 P.126–131

Jeffrey D. Hassebrock, Michael G. Fox, Mark J. Spangehl, Matthew R. Neville, Adam J. Schwartz

Background

The American Academy of Orthopedic Surgeons clinical practice guideline currently recommends repeat joint aspiration when workup of periprosthetic joint infection (PJI) reveals conflicting data. This guideline is based on a single study of 31 patients published 25 years ago. We sought to determine the correlation between first and second aspirations and factors that may play a role in variability between them.

Methods

Sixty patients with less than 90 days between aspirations and no intervening surgery were identified at our institution and classified by Musculoskeletal Infection Society (MSIS) criteria as infected, not infected, or not able to determine after both aspirations. Culture results from both aspirations were recorded. The rates of change and correlation in clinical diagnosis and culture results between aspirations were determined.

Results

Repeat aspiration changed the diagnosis in 26 cases (43.3%, 95% confidence interval 31.6-55.9, kappa coefficient 0.32, P < .001), and the culture results in 25 cases (41.7%, 95% confidence interval 30.1-54.3, kappa coefficient 0.27, P < .01). Among patients initially MSIS negative, the proportion who changed to MSIS positive was greater for those with a history of prior PJI compared to those without (66.7% vs 0%, P < .05), and the first aspiration mean volume was higher for those changed to MSIS positive compared to those that remained MSIS negative (12.0 vs 3.0 mL, P < .01). Among patients initially MSIS positive, the proportion of patients who changed to MSIS negative was greater for those with a history of adverse local tissue reaction (ALTR) to metal debris compared to patients without suspicion of ALTR (100% vs 7.7%, P < .05).

Conclusion

Repeat aspiration is particularly useful in patients with conflicting clinical data and prior history of PJI, suspicion of ALTR, or with high clinical suspicion of infection.

PDF

https://www.arthroplastyjournal.org/article/S0883-5403(18)30749-6/pdf

January 12, 2019 at 10:54 am

Evaluation of Lipocalin-2 as a Biomarker of Periprosthetic Joint Infection

Journal of Arthropasty January 2019 V.34 N.1 P.123–125

Andrea Vergara, Mariana J. Fernández-Pittol, Ernesto Muñoz-Mahamud, Laura Morata, Jordi Bosch, Jordi Vila, Alex Soriano, Climent Casals-Pascual

Background

Periprosthetic joint infection (PJI) remains a major clinical challenge. In this study, we evaluated the diagnostic performance of lipocalin-2 (LCN2), a well-characterized neutrophil protein, in synovial fluid to discriminate PJI and aseptic implant failure.

Methods

Synovial fluid from patients with acute or chronic PJI, aseptic failure, or controls was obtained during surgery. LCN2 was quantified using a modified enzyme immunoassay coupled with chemiluminescence (Architect Urine NGAL; Abbott Laboratories).

Results

Synovial fluid was collected from 72 patients: 22 (30.6%) proven infections, 22 (30.6%) aseptic implant failures, and 28 (38.8%) controls. Synovial fluid was obtained from the hip in 18 (25%) and knee in 54 (75%) cases. Among infections, there were 16 (22.2%) acute and 6 (8.3%) chronic PJIs. The median (interquartile range) LCN2 concentration in synovial fluid was 1536.5 ng/mL (261.8-12,923) in the infection group, 87.0 (54.8-135) in the aseptic group, and 55 (45-67.8) in the control group (P < .001). LCN2 discriminated nearly perfectly between controls and confirmed infection (area under the receiver operating characteristic 0.98, 95% confidence interval 0.95-1.00). The optimal cut-off value for maximal sensitivity (86.3%) and specificity (77.2%) to discriminate aseptic failure versus proven infection was 152 ng/mL, with an area under the receiver operating characteristic of 0.92 (95% confidence interval 0.84-0.99).

Conclusion

LCN2 is a potential novel biomarker that may be helpful to inform surgical teams on the potential risk of PJI and optimize specific surgical interventions as it distinguishes between septic and aseptic failure of prosthesis with high sensitivity and specificity.

PDF

https://www.arthroplastyjournal.org/article/S0883-5403(18)30830-1/pdf

January 12, 2019 at 10:53 am

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